Is There Any Role of Resecting the Stomach to Ameliorate Weight Loss and Sugar Control in Morbidly Obese Diabetic Patients?

Background  Among the restrictive procedures the role of restrictive vs. resecting the stomach is still ambiguous. This study evaluate which is the role of the stomach with respect to blood glucose levels (BG) and percent excess weight loss (EWL) over the 18 months after restrictive procedures in morbid obese diabetic patients. Methods  We retrospectively compared a group of patients who underwent partial gastrectomy (just part of the gastric body) with gastric banding (GBSR; n = 27), sleeve gastrectomy (part of gastric body and complete fundus resection; LSG; n = 53) to laparoscopic gastric banding (LAGB; n = 100). Differences among groups at 3, 6, 12, and 18 months were evaluated by analysis of variance. The three cohorts were diabetic patients similar in BMI, age, and gender. Results  At 12 and 18 months, LSG had higher EWL (P < 0.05) and lower BG (P < 0.05) than did either LAGB or GBSR. There were no operative deaths. Complications: LAGB—two staple-line oozing, two wound infections; LSG—one hemorrhage, two staple-line oozing, two leaks; GBSR—one hemorrhage, two wound infections. All complications were readily treated. Conclusions  LSG provides better weight loss and glucose control at 1 year and 1.5 years after surgery than does either LAGB or GBSR, suggesting that gastric fundus resection plays an important, not yet well-defined, role.     

Gastric Emptying of Semisolids and Pouch Motility Following Laparoscopic Adjustable Gastric Banding

Background  Laparoscopic adjustable gastric banding (LAGB) has been popularized as an effective, safe, minimally invasive surgical technique for the treatment of morbid obesity. We performed a pilot study to evaluate gastric emptying of semisolid meals and antral motility following LAGB. Methods  Gastric emptying half-time was compared in normal volunteers and morbidly obese patients before and 6–12 months after LAGB using sulfur colloid-labeled semisolid meals. Results  There was no difference in mean age between groups. Women were prevalent in the group of obese patients. BMI was higher in patients before surgery (p < 0.001). Patients following LAGB demonstrated prolonged gastric pouch emptying (T1/2 = 36.6 ± 9.8 min) compared to subjects without surgery (23.8 ± 4.7 min) and healthy volunteers (22.8 ± 6.8 min; p < 0.001). Similar gastric contractility was found all groups (3.3 ± 0.4; p = 0.968). No cases of band slippage or pouch dilatation were observed during mean follow-up of 11.4 months. Conclusions  A standard normal gastric pouch emptying rate of semisolids in asymptomatic patients after LAGB was established. Postoperative prolongation of gastric emptying is a matter of mechanical delay without gastric pouch denervation. This study provides a first step of future functional evaluation of complications following this type of bariatric surgery.     

Laparoendoscopic single-site surgery for the placement of an adjustable gastric band: a large cohort comparison

BackgroundLaparoendoscopic single-site (LESS) surgery has been shown to be a well-tolerated alternative for the placement of an adjustable gastric band. To date, only small series have suggested that this approach may provide potential clinical benefits over standard multiport laparoscopy. The objective of this study was to compare the outcomes of patients undergoing LESS adjustable gastric banding (LESS-AGB) and a cohort of patients undergoing standard multiport laparoscopic adjustable gastric banding (LAGB).MethodsA total of 206 patients underwent placement of an adjustable gastric band. Of these, 106 patients underwent LESS-AGB and were compared with a demographically similar cohort of 100 patients who underwent standard LAGB. Data collected included operative time, parenteral and oral narcotic consumption, duration of patient controlled analgesia (PCA) device, subjective pain scores using the 0–10 numeric pain intensity scale, and length of stay. Unpaired t test was used for analysis.ResultsCompared with multiport LAGB patients, LESS-AGB patients reported significantly less pain at the first postoperative hour (P = .012), twelfth postoperative hour (P = .017), and twenty-fourth postoperative hour (P = .012), and consumed fewer oral analgesic tablets (P = .012). Operative times were significantly longer in the LESS-AGB group (P = .029). No significant differences were seen in duration of PCA, parenteral narcotic consumption, or length of stay. One LESS-AGB case required conversion to multiport laparoscopy. Complication rates were similar between the 2 groups.ConclusionLESS-AGB is associated with less pain and less oral analgesic consumption than multiport LAGB. Given these clinical advantages and superior cosmetic results, laparoendoscopic single-site surgery may be an attractive alternative approach for patients considering LAGB. (Surg Obes Relat Dis 2013;0;000–00.) © 2013 American Society for Metabolic and Bariatric Surgery. All rights reserved.     

Combined Laparoscopic Gastric Banding and Stomach Reduction (GBSR): Initial Experience After 1 Year

Purpose We combined laparoscopic adjustable gastric banding (LAGB) and laparoscopic partial gastrectomy into a single procedure (GBSR). Methods The 6- and 12-month percent excess weight loss (EWL) was compared to results expected from the literature for LAGB and laparoscopic Roux-en-Y gastric bypass (LRYGB) using t test. The time to band adjustment was compared with the 6-week period experienced in our setting for LAGB using a sign test. Results Eighteen patients were considered. One patient had gastric leak and had the band removed in postoperative day 1. Seventeen patients were followed-up. The patients, 4 men and 13 women, had a mean age of 38.8 years, an initial mean BMI of 52.4 kg/m², and a mean of 8.3 comorbidities. All required outpatient band adjustment, eight at 4 months, eight at 5 months, and one at 6 months; the median 5 months was greater than the 6 weeks expected for LAGB (P < 0.001). The mean 6-month EWL, 28.6%, was similar to that expected for LAGB (P = 0.24) and less than that expected for LYRGB (P < 0.001). The mean 12-month EWL, 57.4%, was greater than that expected for LAGB (P < 0.001) and less than that expected for LYRGB (P < 0.001). Conclusion Although GBSR’s EWL at 6 and 12 months is less than that of LRYGB, GBSR should be further studied and applied in specific situations only. Presented at SAGES in Las Vegas.     

Laparoendoscopic Single Site (LESS) Cholecystectomy

Introduction  The journey from conventional “open” operations to truly “minimally invasive” operations naturally includes progression from operations involving multiple trocars and multiple incisions to operations involving access through the umbilicus alone. Laparoscopic operations through the umbilicus alone, laparoendoscopic single site surgery (LESS), offer improved cosmesis and hopes for less pain and improved recovery. This study was undertaken to evaluate our initial experience with LESS cholecystectomy and to compare our initial experience to concurrent outcomes with more conventional multiport, multi-incision laparoscopic cholecystectomy. Methods  All patients referred for cholecystectomy over a 6-month period were offered LESS. Outcomes, including blood loss, operative time, complications, and length of stay were recorded. Outcomes with our first LESS cholecystectomies were compared to an uncontrolled group of concurrent patients undergoing multiport, multi-incision laparoscopic cholecystectomy at the same hospital by the same surgeon. Results  Twenty-nine patients of median age 50 years undergoing LESS cholecystectomy from November 2007 until May 2008 were compared to 29* patients, median age 48 years, undergoing standard multiport, multiple-incision laparoscopic cholecystectomy over the same time period. Median operative time for patients undergoing LESS cholecystectomy was 72 min and was not different from that of patients undergoing multiport, multi-incision laparoscopic cholecystectomy (p = 0.81). Median length of hospital stay was 1.0 day for patients undergoing LESS cholecystectomy and was not different from patients undergoing standard laparoscopic cholecystectomy (p = 0.46). Operative estimated blood loss was less than 100 cc for all patients. No patients undergoing attempted LESS cholecystectomy had conversions to “open” operations; two patients had an additional trocar(s) placed distant from the umbilicus to aid in exposure. Three patients undergoing LESS cholecystectomy had complications: two were troubled by pain control and another had urinary retention. Conclusions  LESS cholecystectomy is a safe and effective alternative to standard laparoscopic cholecystectomy. It can be undertaken without the expense of added operative time and provides patients with minimal, if any, apparent scarring. We believe LESS cholecystectomy will be driven by consumer demand, and therefore, laparoscopic surgeons will need to become proficient with LESS procedures.     

Paid Work Increases and State Benefit Claims Decrease after Bariatric Surgery

Background Bariatric surgery is a clinically effective treatment for obesity and has been shown to be costeffective. The impact of bariatric surgery on the subsequent ability to work and the uptake of state-funded benefits is not well documented. Methods A consecutive series of 79 patients who had undergone laparoscopic Roux-en-Y gastric bypass (LRYGBP) or laparoscopic adjustable gastric banding (LAGB) were surveyed to assess changes in their ability to work and the number and type of state benefits claimed after surgery. Results 59 patients (75%) responded, median age 45, median follow-up 14 months. There was a 32% increase in the number of respondents in paid work after surgery (P < 0.05).The mean weekly hours worked increased from 30.1 to 35.8 hours (P < 0.01). Respondents also reported a decrease in obesityrelated physical and emotional constraints on their ability to do work (P < 0.01). Fewer patients claimed state benefits postoperatively (P < 0.01). Conclusion More patients perform paid work after LRYGBP and LAGB than beforehand, and the number of weekly hours they work increases. After surgery, patients claim fewer state benefits.     

Perioperative Outcomes of Laparoscopic Adjustable Gastric Banding in Mildly Obese (BMI < 35 kg/m<Superscript>2</Superscript>) Compared to Severely Obese

Laparoscopic adjustable gastric banding (LAGB) has become a standard restrictive procedure in the USA for the treatment of severe obesity (body mass index, BMI > 35 kg/m²). Mildly obese individuals (BMI < 35 kg/m²) are also at increased risk from obesity-related conditions. Recently, an FDA panel supported its use in this subgroup. We compared the perioperative outcomes of LAGB in mildly and severely obese. Thirty consecutive patients (mildly obese n = 10; severely obese n = 20) that underwent preoperative medical weight loss followed by LAGB procedures were prospectively evaluated. Outcome variables included: operative room (OR) time, intraoperative estimated blood loss (EBL), length of hospital (LOS), and intensive care unit (ICU) stay, reoperations, readmissions, 30-day morbidity and mortality. Demographic data was comparable between groups. BMI was significantly higher in the severely obese compared to mildly obese (44.0 ± 5 vs. 33.6 ± 1 kg/m²). OR time, EBL, LOS, and ICU admissions were similar between BMI groups. There were no reoperations or 30-day mortality in either group. Minor morbidity was only observed in the severely obese group. BMI correlated with OR time and EBL. In mildly obese, LAGB is as safe as in the severely obese with no perioperative morbidity. The perioperative outcomes and hospital resource utilization are comparable between BMI groups. Lower BMI is associated with lower operative times and blood loss.     

A Novel Surgical Technique: Single-Incision Transumbilical Laparoscopic Roux-en-Y Gastric Bypass

Conventional laparoscopic Roux-en-Y gastric bypass (LRYGB) is a gold standard for bariatric surgery, but the procedure requires five to seven incisions for placement of multiple trocars and thus may produce less-than-ideal cosmetic results. We have developed a new approach, single-incision transumbilical LRYGB (SITU-LRYGB) to treat morbid obesity. We compared the surgical results and patient satisfaction in a study of five-port LRYGB and SITU-LRYGB. Fifty morbidly obese patients (14 males, 36 females) underwent either Roux-en-Y gastric bypass with five-port LRYGB or the SITU-LRYGB approach. During the operation, we used a novel intraoperative liver traction method with a “liver suspension tape” that we specifically designed for SITU-LRYGB. Compared to five-port surgery with SITU-LRYGB, there were no intraoperative complications, wound healing was excellent, and there was no abdominal scarring. SITU surgical time was longer than that with five-port LRYGB (99.8 vs. 67.6 min, P < 0.001). Patients treated with the five-port method were more obese than those in the SITU group (127.9 vs. 112.4 kg, P = 0.016). After the bariatric surgery, no difference in comorbidity was found in both groups. Patient satisfaction was greater with SITU than with the five-port method (4.48 vs. 3.96, P = 0.006). Roux-en-Y gastric bypass can be successfully achieved via a single umbilical incision, a method that provides a short operative time and good recovery and eliminates abdominal scarring.     

Palliative stoma creation: comparison of laparoscopic vs conventional procedures

Background  The creation of a stoma is an established therapeutic concept for the palliation of non-resectable rectal carcinomas and advanced tumours infiltrating the pelvis. Materials and methods  In two prospective country-wide multicentre studies, each conducted over a similar period of time, the peri-operative course and postoperative short-term outcomes of laparoscopic vs laparotomy-based stoma construction were compared. Results  A total of 90 patients underwent palliative laparoscopic construction; 550 patients received a stoma via a laparotomy. The intra-operative complication rate was lower after open surgery than after laparoscopic surgery (2.7 vs 5.6%; p = 0.15), although the difference was not significant. With regard to general (30.9 vs 15.6%; p = 0.003) and also specific postoperative complications (13.8 vs 5.6%; p = 0.029), however, a significant advantage of the laparoscopic approach was seen. Furthermore, mortality in the laparoscopic group was also significantly lower (4.4 vs 14.0%; p = 0.011). Conclusion  Palliative stoma done via laparoscopy had significantly better outcomes in terms of postoperative morbidity and mortality in comparison with the open surgical procedure.     

Who Benefits from Gastric Banding?

Background In the present study, criteria were investigated to predict major benefit after laparoscopic adjustable gastric banding (LAGB). Materials and Methods 85 morbidly obese patients were operated with LAGB between 1999 and 2005. Seventy-one of these patients were analyzed according to several possible predictive characteristics for success as the primary endpoint. Success was defined as excess body weight loss (EBWL) >50% and no band removal. Median follow-up was 27 months (range 8–90 months). Results In total, median EBWL was 43% (−41 to 171.5%) with a decrease in BMI of 8.0 kg/m² (−9 to 35 kg/m²). Success rate was 37% (n = 26). These patients were compared to all other patients (n = 45). Significant success predictors were baseline absolute BW, EBW, BMI (p < 0.01), BMI with a threshold value of 50 kg/m² (p = 0.02), and female sex (p = 0.02) as well as postoperative vomiting (p = 0.02), eating behavior and physical activity after LAGB (p < 0.01). Baseline EBW and change in eating behavior after surgery were identified as independent predictors in multivariate analysis. Conclusion Patients with a lower excess body weight who improve especially their eating behavior after surgery have the highest chance of success after LAGB.     

Is Fixation During Gastric Banding Necessary? A Randomised Clinical Study

Anterior fixation via a gastro-gastric suture in laparoscopic adjustable gastric banding (LAGB) is commonly performed to prevent band-related complications. However, the necessity of this common technique has never been proven. Not fixing the band would be time sparing and would reduce adhesions on the stomach and probably make revisional surgery easier. This study was conceived as a 3-year randomised clinical trial to test the safety and efficacy of the non-fixation technique. From December 2006 to December 2007, 81 patients undergoing LAGB were randomly distributed into two groups: group A, with gastro-gastric sutures (n = 41) and group B, without gastro-gastric fixation (n = 40). The two groups were equivalent regarding initial body mass index (BMI), age and sex ratio. The main outcome was postoperative complications and secondary outcomes were operative time and weight loss expressed by the percentage of excess BMI loss (%EBMIL). All patients were prospectively followed up for 2 years. The mean preoperative BMI was 42.5 kg/m2 (35–56). All patients were available for follow-up at 2 years. The mean overall preoperative time was 82 ± 20 min for the fixation group and 72 ± 20 min for the non-fixation group (p = 0.13). The mean hospital stay was 4.1 ± 1.5 days (no significant difference between the two groups). The 2-year %EBMIL was 35.9 for group A and 39.4 for group B (p = NS). The mean BMI at 2 years was 36.3 and 36.1, respectively, with no statistical difference. We observed three early band slippages in the non-fixation group and none in the fixation group. Three bands were removed during the second year of follow-up for causes other than band slippage (no significant difference between the two groups). This study was interrupted before a statistical significance could be reached, under the general agreement of all participating surgeons, because of the three unexpected early band slippages. For the patients who did not suffer from this complication, we did not observe any differences between the two groups in terms of late complications and weight loss. The operative time was shorter in the non-fixation group. This randomised clinical trial suggests that care should be taken when not fixating the LAGB because of the risk of early postoperative band slippage. We suggest that fixing the LAGB by gastro-gastric sutures should remain common practice.     

Crural Repair Permits Morbidly Obese Patients with Not Large Hiatal Hernia to Choose Laparoscopic Adjustable Banding as a Bariatric Surgical Treatment

Background Hiatal hernia, present radiologically in about 50% of patients desiring bariatric surgery, has been thought a contraindication to laparoscopic adjustable gastric banding (LAGB). Posited was the notion that adding crural repair to LAGB would enable this procedure to be offered to patients desiring bariatric surgery who had hiatal hernias. Methods After obtaining IRB approval, charts of all patients who underwent simultaneous crural repair and LAGB from June 2003 to January 2006 were reviewed. All patients were evaluated with the DeMeester score and the GERD-HQRL score pre- and postoperatively. Statistical analyses included the Mann–Whitney U test and the Chi-squared test. Results Twenty-one patients underwent laparoscopic procedure with crural repair; none required conversion to an open procedure. There were no mortalities. Two complications, a wound infection at the level of the port, and a case postoperative dysphagia resolved with therapy. Eighty-six percent of the patients ceased regular intake of heartburn medicines, P < .01. Median percent excess weight loss was 45% at 1 year and 55% at 2 years. The modified DeMeester score fell to 0–2 postoperatively (P < .01). Two years after the procedure, symptoms were less, as assessed by GERD-HQRL scores (P < .01). Conclusion Crural repair permits LAGB to be safely and effectively performed in patients with hiatal hernia.     

Effects of A-Line Autoregression Index (AAI) Monitoring on Recovery After Sevoflurane Anesthesia for Bariatric Surgery

Monitoring depth of anesthesia may improve anesthetic dosing and postanesthetic recovery in obese patients. Sixty morbidly obese patients undergoing laparoscopic adjustable gastric bandage (LAGB) were randomly assigned to receive anesthesia with sevoflurane titrated by either standard clinical parameters (SCP) (target = baseline hemodynamic parameters ± 20%) or by A-line ARX index (AAI) (target = 20 ± 5). Heart rate, arterial blood pressure, inspiratory and expiratory gas concentrations, and AAI were recorded in all patients at 5-min intervals, but AAI was made available only to the anesthesiologist assigned to AAI-monitored patients. Emergence times in surgery room and recovery times in postanesthesia care unit (PACU) were recorded at 1- and 30-min intervals. Mean intraoperative values of AAI were higher in AAI-monitored than in SCP-monitored patients (22.5 vs 15.0, p = 0.001). Compared to SCP monitoring, AAI monitoring reduced consumption of sevoflurane by 20% (p = 0.014), times to eye opening by 2.4 min (p = 0.001) and to extubation by 2.5 min (p = 0.009) and to achieve SpO₂ 92% in room air by 17 min (p = 0.001). Aldrete scores were higher in AAI- than in SCP-monitored patients at arrival in PACU (p = 0.035), but Aldrete scores ≥9 were attained in similar times. AAI monitoring can improve titration of and recovery from sevoflurane for LAGB.     

Six Months of Balloon Treatment does Not Predict the Success of Gastric Banding

Background We studied whether weight loss by intragastric balloon would predict the outcome of subsequent gastric banding with regard to weight loss and BMI reduction. Methods A prospective cohort of patients with a body mass index (BMI) >40 kg/m² received an intragastric balloon for 6 months followed by laparoscopic adjustable gastric banding (LAGB). Successful ballooninduced weight loss was defined as ≥10% weight loss after 6 months. Successful surgical weight loss was defined as an additional 15% weight loss in the following 12 months. Patients were divided in group A, losing ≥10% of their initial weight with 6 months’ balloon treatment, and group B, losing <10% of their initial weight. Results In 40 patients (32 female, 8 male; age 36.6 yr, range 26–54), the mean BMI decreased from 46.5 to 40.5 kg/m² (P < 0.001) after 6 months of balloon treatment and to 35.2 kg/m² (P < 0.001) 12 months after LAGB. Group A (25 patients) and group B (15 patients) had a significant difference in BMI decrease, 12.4 vs 9.0 kg/m² (P < 0.05), after the total study duration of 18 months. However, there was no difference in BMI reduction (4.7 kg/m² vs 5.8 kg/m²) in the 12 months after LAGB. 6 patients in group A lost ≥10% of their starting weight during 6 months balloon treatment as well as ≥15% 12 months following LAGB. 6 patients in group B lost <10% of their starting weight after 6 months of BIB, but also lost ≥15% 12 months following LAGB. Conclusion Intragastric balloon did not predict the success of subsequent LAGB.     

Comparison of Weight Loss and Morbidity after Gastric Bypass and Gastric Banding. A Single Center European Experience

Background Gastric bypass and gastric banding are widely used to treat morbid obesity and both procedures offer certain advantages. The indication for these two treatment options continue to be subject to debate. Methods A single-center case-controlled matched-pair cohort study was performed. Fifty-three primary gastric bypass patients (GB) operated between January 2002 and May 2005 were matched by gender, age, race, and initial bodyweight to 53 patients who underwent laparoscopic adjustable gastric banding (LAGB) in the same time period. Results Both groups were comparable regarding age, race, gender, preoperative body mass index, and excessive weight. Severe early complications occurred in six patients (11.3%) in the GB group and were not seen in the LAGB group. Severe late complications occurred in three patients (5.7%) in the GB group and one patient (1.9%) in the LAGB group. No mortality occurred in either group. Weight loss was significantly lower in the LAGB group than in the GB group at all time points during the follow-up. Significantly more patients were treated successfully (excess weight loss >50%) in the GB group than in the LAGB group. After 2 years, 76% of the patients in the GB group were treated successfully versus 40% of the patients in the LAGB group (P = 0.03). Conclusion Gastric bypass and gastric banding are safe and without mortality. Gastric bypass is more effective in terms of weight loss and the number of successfully treated patients. Gastric banding is a procedure with less severe complications.     

Laparoscopy-Assisted Distal Gastrectomy with D2 Lymph Node Dissection Following Standardization—A Preliminary Study

Background  Laparoscopy-assisted distal gastrectomy (LADG) with standard D2 dissection is a complex procedure usually performed only by experienced surgeons, and the feasibility of this procedure still remains unclear. Method  Patients who underwent LADG at the Cancer Institute Hospital between April 2006 and October 2008 were recruited for this study. Early surgical outcomes were compared between patients who underwent complete D2 dissection (complete D2 group; n = 42) and those who underwent D1 + beta dissection (D1 + beta group; n = 179) to determine the feasibility of laparoscopic D2 lymph node dissection. Results  In complete D2 group, the operation time was longer (253 ± 10 vs 224 ± 4 min; P = 0.005), and the number of retrieved lymph nodes was larger (41 ± 2 vs 35 ± 1; P = 0.002) compared with those in D1 + beta group. The other early surgical outcomes monitored for the two groups were not different between groups. Conclusions  LADG with complete D2 lymph node dissection can be performed safely if the procedure is standardized and an experienced laparoscopic surgeon performs the surgery. To be accepted as a standard treatment for advanced gastric cancer, well-designed prospective trial is necessary.     

Sleeve Gastrectomy and Gastric Banding: Effects on Plasma Ghrelin Levels

Background: Different changes of plasma ghrelin levels have been reported following gastric banding, Roux-en-Y gastric bypass, and biliopancreatic diversion. Methods: This prospective study compares plasma ghrelin levels and weight loss following laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB) in 20 patients. Results: Patients who underwent LSG (n=10) showed a significant decrease of plasma ghrelin at day 1 compared to preoperative values (35.8 ± 12.3 fmol/ml vs 109.6 ± 32.6 fmol/ml, P=0.005). Plasma ghrelin remained low and stable at 1 and 6 months postoperatively. In contrast, no change of plasma ghrelin at day 1 (71.8 ± 35.3 fmol/ml vs 73.7 ± 24.8 fmol/ml, P=0.441) was found in patients after LAGB (n=10). Increased plasma ghrelin levels compared with the preoperative levels at 1 (101.9 ± 30.3 fmol/ml vs 73.7 ± 24.8 fmol/ml, P=0.028) and 6 months (104.9 ± 51.1 fmol/ml vs 73.7 ± 24.8 fmol/ml, P=0.012) after surgery were observed. Mean excess weight loss was higher in the LSG group at 1 (30 ± 13% vs 17 ± 7%, P=0.005) and 6 months (61 ± 16% vs 29 ± 11%, P=0.001) compared with the LAGB group. Conclusions: As a consequence of resection of the gastric fundus, the predominant area of human ghrelin production, ghrelin is significantly reduced after LSG but not after LAGB. This reduction remains stable at follow-up 6 months postoperatively, which may contribute to the superior weight loss when compared with LAGB.     

Inadequate Weight Loss vs Secondary Weight Regain: Laparoscopic Conversion from Gastric Banding to Roux-en-Y Gastric Bypass

Background  Beside complications like band migration, pouch-enlargement, esophageal dilation, or port-site infections, laparoscopic adjustable gastric banding (LAGB) has shown poor long-term outcome in a growing number of patients, due to primary inadequate weight loss or secondary weight regain. The aim of this study was to assess the safety and efficacy of laparoscopic conversion to Roux-en-Y gastric bypass (RYGBP) in these two indications. Methods  A total of 25 patients, who underwent laparoscopic conversion to RYGBP due to inadequate weight loss (n = 10) or uncontrollable weight regain (n = 15) following LAGB, were included to this prospective study analyzing weight loss and postoperative complications. Results  All procedures were completed laparoscopically within a mean duration of 219 ± 52 (135–375) min. Mean body weight was reduced from 131 ± 22 kg (range 95–194) at time of the RYGBP to 113 ± 25, 107 ± 22, and 100 ± 21 kg at 3, 6, and 12 months, respectively, which results in excess weight losses (EWL) of 28.3 ± 9.9%, 40.5 ± 12.3%, and 50.8 ± 15.2%. No statistically significant differences were found comparing weight loss within these two groups. Conclusion  RYGBP was able to achieve EWLs of 37.6 ± 16.1%, 48.5 ± 15.1%, and 56.9 ± 15.0% at 3, 6, and 12 months following conversion, respectively, based on the body weight at LAGB.     

Morbid Obesity and Inflammation: A Prospective Study After Adjustable Gastric Banding Surgery

Background  Inflammatory status underlying obesity seems to be implicated in several aspects of metabolic syndrome. Objective  This study aimed to investigate the association between weight loss achieved by laparoscopic gastric banding (LAGB) surgery, chronic inflammatory markers, and nutritional state. Methods  Thirty-two morbid obese females were enrolled in the study and evaluated at baseline, 1 and 18 months after LAGB surgery. Serum immunoglobulin G (IgG), IgA, IgM, C-reactive protein (CRP), haptoglobin, alpha-1 antitrypsin, total proteins, albumin, prealbumin, transferrin, ferritin, and transferrin soluble receptor were evaluated. In addition, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and fasting glucose were also evaluated. Results  In average, patients presented 18.7% and 63.2% excess body weight loss 1 and 18 months after LAGB, respectively (p < 0.01). CRP and total cholesterol mean levels were elevated (1.03 ± 1.11 mg dL⁻¹ and 2.02 ± 0.41 g L⁻¹) at the presurgery study. CRP mean levels were significantly reduced when compared to reference range (p < 0.01) 18 months after the LAGB surgery. Prealbumin as well as serum total protein mean levels decreased 1 month after surgery (p < 0.01) and values returned to normal at 18 months after surgery. Albumin mean levels showed an increase during the postsurgery evaluations. Serum IgA and IgM concentrations were significantly increased at 1 month after surgery compared to baseline (p < 0.01, both cases). Conclusions  Our results indicate that amelioration of inflammatory markers after LAGB does not seem to negatively impact nutritional status following weight reduction surgery. However, careful attention should be driven to serum IgA. Adequacy of nutritional intake and complete serial laboratory measurements should be always included in the required life-long follow-up of patients surgically treated for morbid obesity.     

Bariatric Surgery Improves Atherogenic LDL Profile by Triglyceride Reduction

Background  Small dense low-density lipoprotein (LDL) are atherogenic particles frequently observed in obese patients. Fatty acids modulate LDL. Objective of this study was to determine the relations between plasma phospholipid fatty acid composition and the presence of small dense LDL particles in morbidly obese patients treated with laparoscopic gastric banding (LAGB). Methods  Small dense LDL, plasma lipids, lipoproteins, apoproteins, and phospholipid fatty acid composition (a marker of dietary fatty acid intake) were quantified before and 12 months after surgery in four men and 11 women who were morbidly obese and (BMI > 40 kg/m²) eligible for surgery, consecutively treated with LAGB at the Department of Medical and Surgical Sciences of the University of Padova. Results  BMI was 48.3 ± 4.8 kg/m² before and 36.1 ± 5.5 kg/m² after LAGB. Plasma triglycerides and apoprotein E levels significantly decreased, while HDL cholesterol significantly increased after LAGB. A reduction of small dense LDL with an increase of LDL relative flotation (0.34 ± 0.04 before vs 0.38 ± 0.03 after LAGB, p < 0.001) was also observed. These modifications were neither related to weight reduction nor to changes in phospholipid fatty acid composition, but they were associated to triglyceride reduction, which explained 76.7% of the LDL relative flotation variation. Conclusion  Weight loss obtained by LAGB in morbidly obese subjects was accompanied by triglyceride reduction, high-density lipoprotein increase, and an improvement of the atherogenic LDL profile. Triglyceride reduction, but not the extent of weight loss or dietary fatty acid modifications, is the determinant of modifications of LDL physical properties in these patients.