Early Clinical and Surgical Results of Biliopancreatic Diversion

Background: Scopinaro biliopancreatic diversion (BPD) for morbid obesity results in significant longterm weight loss and reduction or resolution of obesity-associated co-morbidities. The aim of our work was to describe the early results after BPD. Methods: 59 morbidly obese patients (BMI >40) underwent open BPD from December 2001 to December 2004. We analyzed a consecutive series of 19 patients who have been followed >4 months. We present the data of basal and early visits (2 and 4 months). Results: Initial excess weight percent loss (IEW%L) was 5.2% at 2 months and 13.7% at 4 months. Glycemia, cholesterol, triglyceride levels and blood pressure improved at each visit. All parameters have significant differences from the basal values. 3 patients had sleep apnea syndrome, and overnight CPAP was able to cease in 2 patients by 4 months. 6 patients (31.5%) had albumin <2.5 g/dl, without clinical findings of malnutrition. Total calorie (857±79.8 cal/day) and protein (59.8±23 g/day) intakes at 4 months were low, with a low intake of multivitamins and oligoelements from food. There was no mortality in this series. Early postoperative morbidity was incisional hernia (21.1%), anastomotic leak (5.2%), wound infection (15.7%), intra-abdominal infection (5.2%), and intestinal obstruction (5.2%). Conclusion: BPD showed early effectiveness in weight loss and co-morbidity improvement. Calorie, protein, oligoelement and vitamin dietary intakes were below recommendations, so that strict multidisciplinary follow-up and supplementation to prevent or treat nutritional deficiencies are mandatory.     

Roux-en-Y Gastric Bypass versus a Variant of Biliopancreatic Diversion in a Non-Superobese Population: Prospective Comparison of the Efficacy and the Incidence of Metabolic Deficiencies

Background: In the non-superobese population, an agreement has not been made as to the optimal bariatric operation. The present study reports the results of a prospective comparison of Roux-en-Y gastric bypass (RYGBP) and a variant of biliopancreatic diversion (BPD) in a non-superobese population. Methods: From a cohort of 130 patients with BMI 35 to 50 kg/m², 65 patients were randomly selected to undergo RYGBP and 65 to undergo BPD. All patients underwent complete follow-up evaluation at 1, 3, 6, and 12 months postoperatively and every year thereafter. Results: Patients in both groups have completed their second postoperative year. Mean % excess weight loss (%EWL) was significantly better after BPD at all time periods (12 months, P=0.0001 and 24 months, P=0.0003), and the %EWL was >50% in all BPD patients compared to 88.7% in the RYGBP patients at 2-year follow-up. No statistically significant differences were observed between the 2 groups in early and late non-metabolic complications. Hypoalbuminemia occurred in only 1 patient (1.5%) after RYGBP and in 6 patients after BPD (9.2%). Only 1 patient from each group was hospitalized and received total parenteral nutrition. Glucose intolerance, hypercholesterolemia, hypertriglyceridemia and sleep apnea completely resolved in all patients in both groups, although mean total cholesterol level was significantly lower in BPD patients at the second year follow-up (t-test, P<0.0001). Diabetes completely resolved in all BPD patients and in 7 of the 10 diabetic RYGBP patients. Conclusion: Both RYGBP and BPD were safe and effective procedures when offered to non-superobese patients. Weight loss after BPD was consistently better than that after RYGBP, as was the resolution of diabetes and hypercholesterolemia. Because the nutritional deficiencies that occurred following this type of BPD were not severe and were not significantly different between the 2 operations, both may be offered to non-superobese patients, keeping in mind the severity and type of preoperative co-morbidities as well as the desired weight loss.     

Short-Term Liver Function after Biliopancreatic Diversion

Background: Liver failure after biliopancreatic diversion (BPD) has been reported. Although in our series of 2,515 BPD with a minimum follow-up of 12 months we have never observed this complication, a transitory and significant rise in serum AST and ALT has been detected in some cases, suggesting the occurrence of transient liver damage. To assess if risk factors for acute liver damage after BPD could be identified, we studied the evolution of hepatic biochemistry in a sample of our operated subjects. Methods: We studied 99 consecutive patients submitted to the same type of BPD (ad hoc stomach, ad hoc alimentary limb). Patients with a history of alcohol consumption or positive hepatic serology were excluded. Preoperative body weight (BW), body mass index (BMI), excess weight (EW), % excess weight (%EW), fasting serum glucose level (SG), hepatic histology (HI), weight loss (WL) at 2, 4 and 12 months, and excess weight % loss (IEW%L) at the same time were correlated with preoperative and 2, 4 and 12 months hepatic biochemistry. Results: Compared with preoperative values, AST levels at 2 months significantly increased (Student's t-test, P=0.0003) and significantly decreased at 12 months (P=0.0001). Spearman's Rank test showed significant correlations between 2 months AST levels and WL at 2 months (P =0.005), preoperative BW (P <0.0001), SG (P =0.01), and HI (inflammation P<0.0001, fibrosis P=0.001). Conclusion: Hepatocellular necrosis in our series peaks at 2 months, and decreases afterwards.WL at 2 months, preoperative BW, SG and HI seem to be of help in identifying patients at increased risk for acute liver damage, prompting the need for an enhanced surveillance.     

Calcium and Vitamin D Depletion and Elevated Parathyroid Hormone following Biliopancreatic Diversion

Background: Biliopancreatic diversion (BPD) is associated with a 70% excess weight loss (EWL) at 10 years, but there are concerns regarding long-term nutritional sequelae. Metabolic bone disease has been documented following Roux-en-Y gastric bypass. Methods: Patients who underwent a BPD from 1998 to 2001 were studied. A questionnaire was designed to review BPD patients and collect information on weight loss, frequency of gastrointestinal disturbances and compliance with multivitamin recommendations. The review included a blood test for vitamin D, parathyroid hormone (PTH), alkaline phosphatase (ALP) and calcium. Results: Of the 82 patients who underwent BPD during this period, the median %EWL at 36 months was 73.0%. 75.6% suffered diarrhea. At median follow-up of 32 months (18-50), 25.9% of patients were hypocalcemic, 50% had low vitamin D, 23.8% had elevated ALP, and 63.1% had elevated PTH, despite 82.9% taking multivitamins. Conclusion: BPD results in significant weight loss. However, 1 in 4 patients are hypocalcemic, and 1 in 2 have a low vitamin D, despite multivitamin supplementation. BPD patients require routine calcium and vitamin D supplementation for life. Long-term sequelae from these abnormal serum levels are not known.     

Changes in Liver Histology Accompanying Massive Weight Loss after Gastroplasty for Morbid Obesity

Background: Nonalcoholic steatohepatitis (NASH) is common in morbid obesity. Our goal was to evaluate the alterations in liver histology and biochemistry before and after weight loss in 51 morbidly obese patients following Mason's vertical banded gastroplasty. Methods: Two biopsies were performed (on entry and after an average of 18 months), while 16 of these subjects had a third biopsy 17 months after the second. Results: On entry, steatosis and steatohepatitis (mostly grade 3) were present in 98.0% and fibrosis (mostly stage 2) in 94.1% of the subjects. After an excess weight loss of 66%, steatosis and steatohepatitis improved significantly (P<0.001). Although a significant overall decrease in fibrosis occurred (P=0.002), 21 patients (41.1%) did not change and only 6 patients (11.7%) increased in fibrosis. None developed cirrhosis. The decrease in steatohepatitis was significantly correlated (P=0.011) with the reduction of BMI. Fasting serum glucose, lipids, lipoproteins, transaminases, gamma-glutamyl transpeptidase, alkaline phosphatase and fibrinogen were also significantly improved at the time of the second biopsy. The third biopsy performed in 16 of the subjects showed further significant improvement in liver histology. Conclusion: NASH improved significantly with massive weight loss in non-diabetic, non-alcoholic, morbidly obese subjects, while fibrosis improved in nearly half of the patients.     

Managing metabolic complications of peritoneal dialysis

AIMS: The purposes of this paper are: to report our experience employing a comprehensive, multifaceted treatment program to improve the metabolic disturbances of dyslipidemia, hyperglycemia and weight gain observed in our peritoneal dialysis patients, and by post-hoc analysis to demonstrate how the routine clinical lipid profile can be manipulated arithmetically to estimate levels of atherogenic low-density lipids and thereby achieve a more sophisticated clinical analysis of dyslipidemia and its response to therapy. METHODS: Data are reported for 56 patients who were stable on peritoneal dialysis for at least 6 months and who had metabolic data available prior to beginning peritoneal dialysis. Metabolic complications of peritoneal dialysis were treated by a comprehensive strategy involving diet, glycemic control and lipid-lowering medications with an emphasis on weight control and exercise. From the measured lipid profile (total cholesterol (TC), high-density lipoprotein (HDL) and triglyceride (TG)), levels of atherogenic low-density lipids (low-density lipoprotein (LDL), non-HDL, very-low-density lipoprotein (VLDL) and intermediate-low-density lipoprotein (IDL) were calculated. RESULTS: Before initiation of peritoneal dialysis therapy, the most common lipid abnormalities were low levels of HDL (59%) and elevated levels of triglyceride (41%) with infrequent elevations of total cholesterol (9%) and low-density lipoprotein (23%). After initiation of peritoneal dialysis therapy, all lipid levels, except HDL, increased significantly, and hyperlipidemia, hyperglycemia and obesity, singly or in combination, occurred in 84% of patients. With treatment, elevated lipid levels decreased significantly with reversal of the adverse cardiovascular risk profile of lipids that developed during peritoneal dialysis therapy, and HDL levels increased significantly. On peritoneal dialysis therapy, all diabetic patients required insulin, and glycemic control was achieved in most patients (79%). Excessive weight gain (10-24% body weight) occurred in 20% of peritoneal dialysis patients. Diabetic patients had a higher incidence of being overweight and obese. Post-hoc analysis revealed that levels of VLDL and IDL frequently were elevated both before (57-61%) and during (68-84%) peritoneal dialysis and that target levels of these atherogenic low-density lipoproteins infrequently (22-26%) were achieved. CONCLUSIONS: The metabolic complications of peritoneal dialysis are responsive to a comprehensive treatment strategy. Controlling weight gain on peritoneal dialysis therapy maybe a difficult challenge for some patients, particularly those who are diabetic. Patients with renal failure and on dialysis, especially peritoneal dialysis, frequently have elevated levels of the atherogenic lipoproteins fragments VLDL and IDL. Future clinical trials should focus on the efficacy and safety of aggressive therapy to achieve target levels of these atherogenic lipids.     

Course of Metabolic Syndrome following the Biliopancreatic Diversion of Larrad

Background: The authors assessed the effect of Larrad's biliopancreatic diversion (BPD) on the main components of the metabolic syndrome. Patients and Methods: Plasma concentrations of glucose, insulin, total cholesterol (TC), HDL and LDL cholesterol, triglycerides, LDL/HDL and TC/HDL ratios, and blood pressure and body weight were retrospectively evaluated in 40 patients 3-6, 12, 24 and 60 months after undergoing BPD for morbid obesity with metabolic syndrome. Results: 3-6 months after BPD, glycemia and insulinemia had normalized in 97.5% of the patients and remained stable over the following 5 years. Over this period of 3-6 months to 5 years following BPD, total and LDL cholesterol levels fell by 45.2% and 53.1%, respectively. From 12 months onwards, triglyceride levels decreased appreciably, dropping by 57.4% at 5 years. HDL cholesterol concentrations failed to vary significantly or increased to normal levels in patients showing low initial values. At 5 years, high blood pressure had resolved in 75% of patients and the amount of excess weight lost was 65.5% (±14.6). No patient required reversal of the BPD due to severe gastrointestinal or metabolic complications. Conclusions: Technically adapted to the patient's weight, the Larrad BPD effectively stabilizes the main components of the metabolic syndrome. The BPD has low morbidity rate and should be considered a therapeutic option for patients who do not respond to medical treatment.     

Lipid risk profile and weight stability after gastric restrictive operations for morbid obesity

There are no longitudinal data that address weight loss stability and lipid levels in bariatric surgical patients. The goal of this study was to determine whether weight regain adversely affected reduction in lipid levels after gastric bariatric operations. Of 651 consecutive patients undergoing gastric restrictive surgery for morbid obesity, 227 (35%) had increased serum levels of total cholesterol (TC), triglycerides, or both preoperatively. High-density lipoprotein cholesterol (HDL-C) levels were subnormal (≤35 mg/dl) in 45 (20%) of the hyperlipidemic patients. Fasting lipid profiles were determined at 6-month intervals postoperatively. This series included the following three operations: gastroplasty (GP; N = 13), standard Roux-en-Y gastric bypass (RYGB; N = 205), and distal Roux-en-Y gastric bypass (DRY; N = 9). By 6 months postoperatively, patients had a ≥15% mean reduction in TC and a ≥50% mean reduction in triglycerides, both of which were significant in comparison with preoperative levels (P ≤0.05). Mean HDL-C levels had increased significantly vs. preoperative levels by 12 months postoperatively (P <0.05) and continued to increase through 5 years. By 18 months both HDL-C and TC were significantly lower after DRY than after GP or RYGB. In 91 patients who were followed for 2 years or longer (mean 48 ± 25 months), mean excess weight loss was 55% with mean body mass index reduced from 48 to 33 kg/m². This group was divided into patients whose weight remained stable (N = 54) and patients who regained ≥l5% of their lost weight or lost less than 50% of excess weight (N = 3 7). Although mean excess weight loss and body mass index were significantly different between the two groups (P <0.0001) at 2 years, there was no difference in the lipid profile (TC/HDL) between the two groups at any interval through 5 years. These results show that abnormal lipid profiles can be permanently improved after gastric bariatric surgery and are not adversely affected by mediocre weight loss or regaining ≥15% of lost weight. DRY appears to be a superior operation for TC reduction in comparison with GP and RYGB.     

The Decrease in Plasma Ghrelin Concentrations following Bariatric Surgery Depends on the Functional Integrity of the Fundus

Background: Gastric bypass surgery, which involves the production of a reduced stomach pouch,has been shown to markedly suppress circulating ghrelin concentrations. Since bypassing the ghrelin-producing cell population may be relevant to the disruption of fundic-derived factors participating in food intake signaling, the effect of weight loss induced by either adjustable gastric banding (AGB), Roux-en-Y gastric bypass (RYGBP) or biliopancreatic diversion (BPD) was studied. Methods: 16 matched obese patients [35.0 + 2.4 years; initial body weight 124.8 ± 5.7 kg; body mass index (BMI) 47.1 ± 2.2 kg/m²] in whom similar weight loss had been achieved by either AGB (n=7), RYGBP (n=6) or BPD (n=3) were studied. Blood was obtained for biochemical and hormonal analyses. Body composition was assessed by air-displacement-plethysmography. Results: Comparable weight loss (AGB: 26.1 ± 5.1 kg; RYGBP: 32.1 ± 5.0; BPD: 31.7 ± 6.1; P=NS) and decrease in percentage body fat (AGB: 10.0 ± 1.5%; RYGBP: 14.2 ± 2.8; BPD: 10.3 ± 1.0; P=NS) induced by bariatric surgery exerted significantly different (P=0.004) effects on plasma ghrelin concentrations, depending on the surgical procedure applied (AGB: 480 ± 78 pg/ml; RYGBP: 117 ± 34; BPD: 406 ± 86). Without significant differences in BMI, body fat, glucose, triglycerides, cholesterol, insulin and leptin levels, patients who had undergone the RYGBP exhibited statistically significant diminished circulating fasting plasma ghrelin concentrations compared with the other two bariatric techniques which conserve direct contact of the fundus with ingested food (P=0.003 vs AGB and P=0.020 vs BPD). Conclusion: Fasting circulating ghrelin concentrations in patients undergoing diverse bariatric operations depend on the degree of dysfunctionality of the fundus.     

Resolution of hyperlipidemia after laparoscopic Roux-en-Y gastric bypass

BACKGROUND: Hyperlipidemia is an established risk factor for development of coronary artery disease. The aim of our study was to examine the changes in serum lipid profiles of morbidly obese patients complicated by hyperlipidemia, who underwent laparoscopic gastric bypass. STUDY DESIGN: We retrospectively reviewed the charts of 95 morbidly obese patients with documented hyperlipidemia who underwent laparoscopic gastric bypass. Mean duration of hyperlipidemia was 44+/- 56 months. Hyperlipidemia was defined as an elevated level of triglycerides (> 150 mg/dL) or total cholesterol (> 200 mg/dL). Changes in lipid profile of a subset of patients with subnormal levels of high-density lipoprotein cholesterol ( 130 mg/dL), and very-low-density lipoprotein cholesterol (> 40 mg/dL) were also examined. Fasting lipid profiles were measured preoperatively and at 3-month intervals. RESULTS: There were 68 women (72%) with a mean age of 43 +/- 10 years. Mean body mass index was 47+/- 5 kg/m2. Mean percentage of excess body weight loss at 12 months postoperatively was 66%. One year after gastric bypass, mean total cholesterol levels decreased by 16%; triglyceride levels decreased by 63%; low-density lipoprotein cholesterol levels decreased by 31%; very-low-density lipoprotein cholesterol decreased by 74%; total cholesterol/high-density lipoprotein cholesterol risk ratio decreased by 60%, and high-density lipoprotein cholesterol levels increased by 39%. Also, within 1 year, 23 of 28 (82%) patients requiring lipid-lowering medications preoperatively were able to discontinue their medications. CONCLUSIONS: Weight loss after laparoscopic gastric bypass substantially improves lipid profiles in morbidly obese patients who have hyperlipidemia. Improvement in lipid profiles was observed as early as 3 months postoperatively and was sustained at 1 year. Improvement of lipid profiles after laparoscopic gastric bypass can reduce health risks associated with high levels of atherogenic lipoproteins.     

Body Contouring after Biliopancreatic Diversion

Background: From Nov 2001 to Mar 2006, 176 patients underwent body contouring plastic surgery after prior biliopancreatic diversion (BPD). Weight loss had varied from 30-100 kg. The plastic surgery targeted the arms (24 patients), breast (58), abdomen (62) and thighs (20), plus torsoplasty (12). Methods: BPD is a "non-cosmetic" bariatric operation which results in malabsorption and subsequent major weight loss within 12 to 18 months. The typical "empty" aspect of the slimmed areas directed our surgical choices to specific techniques: brachioplasty, reduction mammaplasty and/or mastopexy (with or without prosthesis or "self-prosthesis" technique), thigh-lift, abdominoplasty and torsoplasty. We do not consider any liposuction technique suitable for this kind of patient, because of the specific histological changes caused by BPD. Results: The metabolic discrepancies following BPD affect postoperative management of these patients. A higher incidence of complications has been reported, of both systemic and local nature; the local ones, common in the abdominal wall, convinced us to perform an arteriographic study preoperatively, to check anatomical alterations following the BPD. Conclusions: Although the characteristics of BPD patients limit the choices, we are satisfied with the results of cosmetic correction and quality of life. All the patients, without exception, noted a high rate of positive thinking and have undergone further body-contouring surgery (or plan to do so).     

Type 2 Diabetes and Weight Loss following Biliopancreatic Diversion for Obesity

Background: The authors investigated the weight loss and maintenance in type 2 diabetic obese patients undergoing biliopancreatic diversion (BPD). Methods: Two series of diabetic and non-diabetic obese patients matched for gender, age and baseline body mass index (BMI) were evaluated prior to BPD, on the occasion of the regular follow-up visit at 1, 2 and 3 years following the operation, and at the fifth postoperative year. At each follow-up point, body weight (BW), BMI, and serum glucose concentration were measured. Results: In all type 2 diabetic patients, the serum glucose level fell to within the normal range at the first postoperative year and remained within normal limits without any medication throughout all the follow-up period. In preoperatively diabetic subjects, mean values of BW and BMI were closely similar to those of non-diabetic subjects at all follow-up points, and the stabilization weight was independently related to age and to initial BW values. Conclusions: In obese patients with type 2 diabetes, the glucose level steadily normalized in every case following BPD, and values remained unchanged throughout the follow-up period. After the operation, the type 2 diabetic obese patients experienced the same stable weight reduction as their non-diabetic counterparts.     

Impact of Age on Long-Term Complications after Biliopancreatic Diversion

Background: The aim of the study is to evaluate the importance of age on the mid- and long-term results and complications after biliopancreatic diversion (BPD). Methods: Our study comprises 132 morbidly obese patients who underwent Scopinaro BPD from February 1995 to April 2001, with follow-up from 24 to 96 months. The patients, 53 males (40%) and 79 females (60%), with mean preoperative BMI 50.2 (35.4-81.5), and mean age 42 (20-65), were divided in 4 groups. Group A age 20-35, 43 patients; Group B age 36-45, 33 patients; Group C age 46-55, 31 patients and Group D age >55, 25 patients. Incidence of long-term specific complications after BPD were analyzed, including protein malnutrition, reversals, anastomotic ulcer, and incisional hernia. Results: Mean postoperative BMI was similar in all Groups. After 60 months the following BMI values were observed. Group A 30.8, Group B 34.9, Group C 35.9, Group D 32. Incidence of long-term complications were not significantly different (χ²) in the 4 Groups, and were respectively: protein malnutrition 6.9%, 12.1%, 6.4%, 16.0%; anastomotic ulcer 11.6%, 9%, 6.4%, 16.0%; reversal 2.3%, 9.0%, 1.32%, 8.0%; ventral hernia 34.8%, 45.4%, 54.8%, 32.0%. Conclusions: From the preliminary results, it appeared that the incidence of the complications was higher in group D (>55 years old), whereas group C (46-55 years old) showed a lower complication rate. However, the prevalence of complications in all groups was not statistically different on χ² analysis. No age limit for bariatric surgery could be determined from the age ranges studied.     

Laparoscopic biliopancreatic diversion: technique and initial results

Background: Biliopancreatic diversion (BPD) is an efficient method for treating morbid obesity.We present the BPD technique by laparoscopy and the 1st year follow-up. Methods: From July 2000 to April 2001, 40 patients underwent laparoscopic BPD (29 women, 11 men), with average age 39 (17-60). Average BMI was 43.6 kg/m2 (38-65). All operations were completed sucessfuly by laparoscopy. The technique followed strictly the operation of Scopinaro. 7 of these patients had removal of an adjustable gastric band and were converted to BPD. All underwent cholecystectomy. Results: Mean loss of initial excess weight at 3, 6 and 10 months was ≈ 30%, 50% and 90%. Mortality was 2.5% (1 patient) due to massive pulmonary embolism. Average operating time was 210 minutes (130-480), and average hospital stay was 4.3 days (3-21). There were 5 postoperative complications (12.5%): 2 pulmonary emboli, 2 GI bleeding from the staple-line, and 1 fistula.There have been 5 late complications (12.5%): 3 cases of diarrhea, 2 elevated PTH with normal calcium, and hypothyroidism that was dificult to control. Conclusion: BPD may be performed by laparoscopy without changes in the original technique or in the early results.     

Disturbed Lipids,Lipoproteins and Triglyceride-Rich Lipoproteins as Well as Fasting and Nonfasting Non-High–Density Lipoprotein Cholesterol in Post-Renal Transplant Patients

Serum levels of lipids and lipoproteins were determined in 98 post-renal transplant fasting patients, and lipids and non-high density lipoprotein-cholesterol (non-HDL-C) and lipid ratios in the same post-renal transplant non-fasting patients were compared. The reference group was 87 healthy subjects. All patients were divided into two groups: patients with dyslipidemia (n?=?69) and patients with normolipidemic (n?=?29). The post-renal transplant patients (TX) with dyslipidemia had a significantly increased concentration of triglyceride (TG), low-density lipoprotein-cholesterol (LDL-C), non-HDL-C, apoB, and TRL and lipid ratios, and decreased HDL-C level and lipoprotein ratios. The lipids, lipoproteins, and lipoprotein ratios were significantly beneficial in TX patients with normolipidemic than in those with dyslipidemia. However, TRL concentration and lipid ratios were significantly increased and apoAI/apoCIII significantly decreased as compared to the reference group. The TX patients with dyslipidemia showed a significant correlation between TG and apoB:CIII (r?=?0.562, p < 0.001) and apoCIII (r?=?0.380, p < 0.004), but those with normolipidemic showed a significant correlation only between TG and apoCIII (r?=?0.564, p < 0.008). Regression and Bland-Altman analyses showed excellent correlation between fasting and nonfasting non-HDL-C levels (r?=?0.987, R² + 0.987) in TX patients both with dyslipidemia and normolipidemic. We think the finding that nonfasting labs that are reliable for non-HDL-C as well as total cholesterol is important, as fasting labs are not always available. Disturbances of lipids, lipoproteins, and TRLs depend not only on the kind of treatment, but due to multiple factors can accelerate cardiovascular complications in post-renal transplant patients with dyslipidemia and also with normolipidemic. Further studies concerning this problem should be completed.     

The Intragastric Balloon – Smoothing the Path to Bariatric Surgery

Background: Intragastric balloon placement in association with diet for weight reduction is steadily gaining popularity. However, long-term follow-up studies on the effect of this method in maintaining weight loss are lacking. This study evaluated the long-term outcome following balloon removal in morbidly obese patients who had selected this method for weight loss. Methods: 140 morbidly obese patients who refused bariatric surgery because of fear of complications and mortality, underwent intragastric balloon placement and were followed over a 6- to 30-month period (mean 18.3 months) after balloon extraction. The 34 males and 106 females, with median age 38 years (range 16-62), median weight 122 kg (range 85-203), median BMI 42.3 kg/m² (range 35-61.3) and median excess weight (EW) 59 kg (range 29-132), received a Bioenterics Intragastric Balloon (BIB). Excess weight loss (EWL) ≥25% when the BIB was removed was considered a success. Weight fluctuations and any further interventional therapy requested by the patients after balloon removal were recorded. Results: 100 patients (71.4%) lost ≥25% of their EW on balloon extraction and were categorized as successes, while 40 patients (28.6%) did not achieve that weight loss and were categorized as failures of the method. During the follow-up period, 44 of the originally successful patients (31.4%) regained weight and were categorized as recurrences, while the remaining 56 patients (40%) maintained their EWL of ≥25% and were considered long-term successes. During follow-up, 45 patients (32.1%) requested and underwent bariatric surgery for their morbid obesity (21 Adjustable Gastric Band, 11 Laparoscopic Sleeve Gastrectomy, 13 Laparoscopic Gastric Bypass). Of these, 13 (32.5%) were from the group of 40 patients categorized as failures on BIB removal, 28 (63.6%) were from the group of 44 patients whose obesity recurred, and 4 (7.1%) were from the 56 patents who although they maintained successful weight loss requested further weight reduction. Conclusions: The BIB served as a first step and a smooth introduction to bariatric surgery for morbidly obese patients who initially refused surgical intervention. The incidence of surgical intervention was double in patients who initially experienced the benefits of weight loss and then had obesity recurrence, compared with patients in whom the method failed. Indeed, a significant number of patients were assisted in their efforts to lose and maintain an acceptable weight loss over a 6- to 30-month follow-up period.     

A Comparison of Laparoscopic Adjustable Gastric Banding and Biliopancreatic Diversion in Superobesity

Background: Controversy exists regarding the best surgical treatment for superobesity (BMI >50 kg/m²), and a comparison of the 2 most commonly performed procedures in Europe, namely biliopancreatic diversion (BPD) and laparoscopic adjustable gastric banding (LAGB), has not yet been reported. Methods: BPD has been performed in 134 morbidly obese patients since 1996, and as the primary bariatric procedure in 23 superobese patients. 23 sex-matched patients who most closely resembled the age and BMI of the 23 BPD patients were chosen from 1,319 patients who had undergone LAGB since 1996. These groups were compared using appropriate statistical tests. Results: BPD was performed laparoscopically in 12 patients. Median excess weight loss at 24 months was 64.4% following BPD and 48.4% following LAGB. Hospital stay and complication rate were significantly greater with BPD, although the majority of complications were related to the laparotomy wound in patients undergoing open BPD. Rate of resolution of obstructive sleep apnea, hypertension and diabetes mellitus following LAGB was similar to BPD. Conclusion: BPD results in significantly greater weight loss than LAGB in superobese patients, but is associated with a longer hospital stay and a higher complication rate in patients undergoing open BPD.     

Results of Biliopancreatic Diversion after Five Years

Background: Gastric restrictive procedures, currently the most popular surgical operations for morbid obesity, have proved to be effective in initiating weight loss, but questions regarding their long-term efficacy in weight maintenance have arisen. Biliopancreatic diversion (BPD) is a mixed and complex technique that has shown good long-term results. There are no series with long-term follow-up of BPD in Spain. We present >5 year results (average 67.9 ± 15 SD mons, range 48-96), evaluating weight loss, morbidity and mortality after BPD. Methods: 74 patients who underwent BPD and completed 5 or more years of follow-up were studied. The results have been analyzed in terms of weight loss (classification of Reinhold), improvement in morbidity, and improvement in quality of life (BAROS). Results: 78.6% were women. Mean age was 38 ± 11 years (18-61). Mean preoperative body mass index (BMI) was 54 ± 8 kg/m². Progression of BMI: 1 year 34 ± 6, 2 years 31 ± 6, 5 years 33 ± 7 and 7 years 31 ± 3 kg/m² . Excess weight loss at 1 year follow-up was 67%, at 2 years 75%, at 5 years 70% and at 7 years 71%. There were significant differences between morbidly obese (BMI <50 kg/m²) and super-obese (BMI >50 kg/m² ), with better results in the morbidly obese group. Conclusion: BPD shows long-term effectiveness in weight loss, co-morbidity improvement and quality of life. Protein, vitamin and oligoelement deficits may appear in the long-term, so that strict follow-up and supplementation of deficiencies are necessary.     

Hyperlipidemia in pediatric patients undergoing peritoneal dialysis

We evaluated serial measurements of serum lipid levels in 68 patients aged 12.6±4.7 years undergoing treatment with continuous ambulatory peritoneal dialysis/continuous cycling peritoneal dialysis (CAPD/CCPD). Fasting mean levels of triglycerides (TG) and cholesterol (C) were elevated above the 95th percentile of published normal values by 102% and 19%, respectively, at the start of dialysis. Except for a shortterm decrease in TG levels at 6 and 9 months, no significant change in mean lipid levels was observed during a follow-up period of 2 years. At initiation of dialysis, elevated TG and C levels were present in 90% and 69% of the patients, respectively. The prevalence of hyperlipidemia (HL) varied between 63% and 88% (TG) and 61% and 93% (C), respectively, during the follow-up period. TG and C levels were not correlated with caloric intake (evaluated in 17 patients), serum albumin levels, treatment modality (CAPD or CCPD), a history of the nephrotic syndrome, or previous treatment with hemodialysis or transplantation. However, a significant inverse correlation was observed between age and serum lipids at the initiation of dialysis treatment and after 1 year (TG:r=–0.40; C:r=–0.44). Our data indicate a high prevalence of HL but no significant change of serum lipid levels during 2 years of treatment with CAPD/CCPD.     

Laparoscopic Reoperative Sleeve Gastrectomy for Poor Weight Loss after Biliopancreatic Diversion with Duodenal Switch

Background: The revisional surgery for patients with inadequate weight loss after biliopancreatic diversion with duodenal switch (BPD/DS) is controversial. It has not yet been determined whether a common channel should be shortened or gastric pouch volume reduced. Since the revision of the distal anastomosis remains technically difficult and associated with possible complications, we turned our attention to the reduction of gastric sleeve volume. This operation is more feasible and potential complications are less probable. Patient and Method: We present the case of a 47-year-old women with a life-long history of morbid obesity. She was operated on in January 2000 with a laparoscopic BPD/DS with 100 ml gastric pouch, 150 cm of alimentary limb and 100 cm of common channel. Before this operation, her weight was 170 kg, with BMI 64 kg/m². She lost most of her excess weight within 17 months after surgery and was regaining weight at 77 kg and BMI 29 kg/m². Upper GI series showed a markedly dilated gastric pouch. Her second surgery consisted of a laparoscopic sleeve partial gastrectomy along the greater curvature using endo GIA staplers with bovine pericardium for reinforcement of the stapler line. Results: No postoperative complications occurred. The patient was discharged on the first postoperative day. Significant further weight reduction was noted, and at 10 months after surgery, her weight is 61 kg with BMI 22. Conclusion: A repeat laparoscopic gastric sleeve resection was performed for inadequate weight loss after BPD/DS, and resulted in further weight reduction.