Micronutrient Deficiencies After Laparoscopic Gastric Bypass: Recommendations

Background  The aim of this study was to evaluate the changes of micronutrients in patients with morbid obesity after laparoscopic Roux-en-Y gastric bypass surgery (LRYGBP). Methods  We retrospectively reviewed 121 patients diagnosed with morbid obesity who undertook LRYGBP and evaluated the serum iron (Fe), calcium (Ca), zinc (Zn), selenium (Se), vitamin A (VitA), 25-hydroxy vitamin D3 (VitD), vitamin B₁₂ (VitB₁₂), and parathormone (PTH) measured at 6, 12, and 24 months after LRYGBP. Results  During a follow-up period of 69 months (June 1999 to February 2005), a cohort of 121 patients, 40 men and 81 women, underwent LRYGBP, a mean age of 46 years (range 22–67). The mean body mass index (BMI) before LRYGBP was 47.00 ± 7.15 kg/m² (range 30.65–76.60 kg/m²). After 6 months of the surgery, the mean BMI was 33.79 ± 6.06 kg/m² (range 21.70–52.76 kg/m²). The mean BMI decreased (P < 0.001) 6 months after the surgery. Within the following 2 years, the serum Fe, Ca, Zn, Se, VitA, VitD, and VitB₁₂ had normalized. The serum Zn, Se, and VitA of some patients decreased but were nearly normal. In contrast, serum PTH remained continuously at a higher level than normal. Conclusions  This study confirms that LRYGBP is a reliable and safe weight loss method for the patients suffering from morbid obesity. After surgery, serum Ca, Zn, and Se metabolisms and PTH levels are altered in these patients. Therefore, multi-vitamin and mineral supplementation are strongly recommended in all patients after LRYGBP.     

Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity: Results of our Learning Curve in 100 Consecutive Patients

Background: Morbid obesity requires life-long treatment, and bariatric surgery provides the best results. Among the bariatric procedures, laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been considered to be superior. However, it requires advanced laparoscopic skills and a learning curve. We analyzed our results in an initial series of 100 patients. Methods: Data of 100 consecutive patients who underwent LRYGBP for morbid obesity in a 2.5-year period were prospectively collected and analyzed with emphasis on results and complications. Results: Mean age was 31±5 years. There were 63 woman and 37 men. Preoperative BMI was 50±9 kg/m². 33 patients were considered super-obese (BMI>50). Mean operative time was 3.8 ± 0.7 hours. Two patients required conversion to open surgery. Mean hospital stay was 6 days. Complications occurred in 10 patients. Mortality rate was 2%. Excess body weight loss was as follows: 33 ± 8% at 3 months (n=92), 47 ± 2% at 6 months (n=82), 62 ± 4% at 1 year (n= 70), 66 ± 5% at 18 months (n= 63) and 67 ± 8% at 2 years (n= 35). There was significant improvement in several co-morbid conditions, such as diabetes and hypertension. Conclusion: LRYGBP is a reproducible technique. It requires the combination of bariatric and laparoscopic expertise.     

Gastrointestinal Quality of Life Following Laparoscopic Adjustable Gastric Banding in Asia

Background: Laparoscopic adjustable gastric banding (LAGB) is a safe and effective treatment for morbid obesity. Previous studies in Western countries disclosed a significant improvement in co-morbidities and health-related quality of life. Data from Asia and regarding the specific GI quality of life following LAGB are lacking. Methods: From May 2002 to May 2005, 107 consecutive patients – 48 men and 59 women, with mean age 31.4 years (range 17-57 years) with morbid obesity (mean weight 115.8 kg, range 81-174 kg; mean BMI 41.3 kg/m², range 32.0-59.8 kg/m²) underwent LAGB in a prospective trial. All bands were placed via the pars flaccida technique. Quality of life was measured by the Gastrointestinal Quality of Life Index (GIQLI), a 36item questionnaire before LAGB, and at 3, 6, 12 and 24 months after surgery. Results: All procedures were performed laparoscopically with no conversions. There was neither intra-operative complications nor major postoperative complications. Minor complications occurred in 3 patients (2.8%); all were transient stoma obstruction. At follow-up, only one band (0.94%) was removed at 3 months postoperatively because of the patient's intolerance. No gastric slippage occurred. 4 patients (3.7%) had tubing problems and required revision surgery for port adjustment. Mean BMI decreased from 41.3 to 33.1 after 2 years. Percent excess BMI loss averaged 48.1% at 2 years (range 6.7-139.2). All co-morbidities were eliminated significantly. 80% of patients were satisfied with the results at 2 years. However, the GIQLI score remained similar before and after surgery. Preoperative score was 110.8+15 points. The score became 116.2+13, 114.7+13, 108.5+14 and 107.2+17 at 3, 6, 12 and 24 months. The patients had improvement in 3 domains of general health (social, physical and emotional functions), but decrease in the domain of symptoms. Conclusion: Although LAGB was successful in weight loss and resolution of co-morbidities in morbidly obese patients, the GIQLI did not improve. This feature will be the major disadvantage of LAGB.     

Psoriasis Remission after Laparoscopic Roux-En-Y Gastric Bypass for Morbid Obesity

Background: Psoriasis is a chronic skin disease characterized by epithelial hyperplasia and an accelerated rate of epithelial turnover affecting approximately 1-3% of the population. Exogenous and endogenous factors including morbid obesity can increase the morbidity of psoriasis. Case Report: A 55-year-old male, who weighed 131 kg with BMI 41 kg/m², underwent laparoscopic Roux-en-Y gastric bypass (LRYGBP). He had a 15-year duration of severe psoriasis and was being medically treated. At 12 months after LRYGBP, he had lost 39 kg (68% EWL), and had complete resolution of the psoriasis and had discontinued all preoperative medications related to the disease. At 2 years after LRYGBP, psoriasis has not recurred. Conclusion: Weight loss after LRYGBP should be considered as a strategy in the treatment of severe psoriasis in morbidly obese patients.     

Laparoscopic Gastric Bypass after Antireflux Surgery for the Treatment of Gastroesophageal Reflux in Morbidly Obese Patients: Initial Experience

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been proven effective against gastroesophageal reflux disease (GERD) in morbidly obese patients. We present our experience with revision of antireflux procedures to LRYGBP in obese patients with recurrent GERD, weight gain or a combination of both and discuss the indications and technical considerations involved. Methods: Between June 2000 and December 2003, 7 morbidly obese patients with a mean BMI of 37.5 kg/m² underwent revision of an antireflux procedure to LRYGBP by our group. Important steps of the revision include dissection of the diaphragmatic crura and gastroesophageal fat pad, reduction and repair of hiatal hernia, and complete take-down of the wrap to avoid stapling over the fundoplication which can create an obstructed, septated pouch. Results: Mean operative time was 6 hr 12 min and length of stay was 4.8 days. There were 3 major complications postoperatively and no deaths. During follow-up, 5 patients developed anastomotic strictures and 2 patients were re-explored for gastric remnant herniation and intestinal obstruction. At a mean follow-up of 24 (3-44) months, mean excess weight loss was 70.7% and 14/20 (70%) co-morbid conditions were improved or resolved. GERD evaluation with the GERD-HRQL scale showed a significant reduction of GERD scores postoperatively (P =0.006). Conclusions: Although LRYGBP after antireflux surgery is a technically more difficult procedure with a higher morbidity, it is feasible and effective for the treatment of recurrent GERD and worsening obesity with the additional advantage of weight loss and improvement of co-morbidities.     

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.     

Results of Laparoscopic Gastric Bypass in Patients ≥55 Years Old

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a commonly performed surgical intervention for morbid obesity. Some authors considered age ≥55 years as a relative contraindication to bariatric surgery. We examined the operative outcomes, weight loss, hospital stay and resolution of co-morbidities in patients ≥55 years old compared with those <55 years old undergoing LRYGBP. Methods: From Jan 2000 to Feb 2005, 350 LRYGBPs were performed. 48 patients ≥55 years old (13.7%) were compared to the remaining patients. Results: Analysis of the 48 patients ≥55 years old compared with 302 patients <55 revealed no difference in complication rate, although the older patients had a significantly greater percentage of serious complications. Younger patients lost more weight than older patients. Both groups demonstrated resolution of comorbidities, although the difference was not significant. Conclusions: LRYGBP is safe and well tolerated in morbidly obese patients ≥55 years. The older patients had more serious complications and lost less weight; however, their weight loss and resolution of co-morbidities improved their quality of life. Age should not be a contraindication to bariatric surgery.     

Biliopancreatic Diversion for Treatment of Morbid Obesity: Experience in 180 Consecutive Cases

Background: Biliopancreatic diversion (BPD) by Scopinaro's method is used by many as a surgical treatment for morbid obesity. The authors present their results in 180 consecutive cases. Method: Between June 1995 and May 1998, the authors performed BPD by Scopinaro's method on 180 patients (36 men) with morbid obesity, mean age 35.8 years (range 18-58 years), mean body mass index (BMI) 48.8 kg/m² (range 35-66 kg/m²). Results: In all cases, a gradual decrease in weight was obtained: the mean BMI at 1 month was 40.3 kg/m², at 6 months 34 kg/m², at 1 years 32 kg/m², at 18 months 30.2 kg/m², and at 36 months 28.8 kg/m². At the same time a significant improvement in the pathologic conditions associated with morbid obesity was observed. Postoperative complications were two duodenum blowout syndromes requiring prolonged intensive care, and an 18% rate of incisional hernias. Conversion to normal small bowel continuity was necessary in three cases. Protein malnutrition developed in 2 patients (1.1%), in 1 patient coinciding with addiction to cocaine. One patient could not psychologically accept the physical changes and requested conversion. Anastomotic ulceration was seen in 11% of the patients. Operation for late obstruction occurred in 2 patients. There was no mortality. Conclusions: Although BPD by Scopinaro's method is technically complex, it is safe and effective.     

Bariatric Surgery in Adolescence. Is this the Best Age to Operate?

Background: Bariatric surgery in morbidly obese adolescents is controversial. Many argue that morbidly obese individuals should be of adult age before undergoing bariatric operations, despite the progressive and debilitating course of this increasingly common disease. Materials and Methods: 19 consecutive adolescent patients, aged 13-17, underwent vertical banded gastroplasty-Roux-en-Y gastric bypass between May 1990 and August 2001. Average BMI was 49 kg/m², range 38-67. All had one or more co-morbidities. Follow-up was obtained up to 10 years. Results: Postoperative BMI at the maximum time of follow-up, mean 5.5 years (range 1-10 years), was 28 (range 23 to 45). Only one patient did not lose enough weight and was considered a failure. There were two revisions and no mortality or morbidity. All co-morbidities disappeared. Family and patients were pleased with the surgery. Conclusions: Early surgical intervention should be offered to a greater number of adolescents to minimize the emotional and physical consequences of morbid obesity.     

Long-term Follow-up on the Effect of Silastic Ring Vertical Gastroplasty on Weight and Co-Morbidities

Background Silastic ring vertical gastroplasty (SRVG) is a simple, effective and reproducible restrictive operation for the treatment of morbid obesity. Over the last years, it has lost its popularity due to the development of adjustable gastric banding systems performed laparoscopically. In order to evaluate the long-term effect of SRVG on weight loss and co-morbidities, we reviewed the results of SRVG operations in our institution. Methods We reviewed SRVG operations performed in our University-affiliated General Hospital. Data was collected from the patients’ in-patient records, their outpatient-clinic files, and from a telephone interview. Results Between 1989 and 2001, 162 patients were operated upon. Complete follow-up was obtained of 115 patients (71%). The mean follow-up was 7.1 ± 3 years (range 4 to 16 years). Mean preoperative BMI was 47 kg/m2 (range 34 to 69 kg/m²). Maximal weight loss was obtained within 1 year to a mean BMI of 29 kg/m², with a mean excess BMI loss of 67%. Subsequently, there was a small increase in BMI, which stabilized at 34 kg/m² up to 15 years after the operation. A rapid, significant improvement in obesity-related co-morbidities was observed regarding hypertension (81%), diabetes (100%), sleep disorders (90%), osteoarthritis (83%) and ischemic heart disease (75%). There was no peri-operative mortality. Early complication rate was 10%. Late complications included postoperative ventral hernia (18%), esophagitis (31%), ring stricture (19%), ring erosion (2 patients), failure of staple line (8%) and obstruction of the pouch with food (19%). 35 patients (30%) required another procedure, 8 of them were eventually converted to other bariatric operations, and 2 patients had the ring removed and refused another bariatric procedure. The overall satisfaction rate was 86%. Conclusions SRVG is a simple, safe and effective bariatric operation in selected patients with morbid obesity. It results in a rapid, excellent effect on obesity-related co-morbidities and good long-term effect in weight loss, which compares positively with other, more complicated bariatric operations.     

Gastrointestinal Quality of Life after Laparoscopic Roux-en-Y Gastric Bypass

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a commonly performed bariatric surgical procedure for the treatment of morbid obesity (MO). Obesity-related co-morbidities reduce the quality and expectancy of life. We assessed gastrointestinal quality of life in patients following LRYGBP. Methods: The Gastrointestinal Quality of Life Index (GIQLI test) was used in this study. A higher score correlates with better quality of life. The GIQLI test was administered to 3 non-selected groups: 100 morbidly obese patients (MO group), 100 patients who had undergone LRYGBP (LRYGBP group); and a control group of 100 individuals (CO group). The CO group was composed of healthy individuals with a BMI <30 kg/m², consecutively recruited among the companions of patients who came for a surgery consultation for obesity or other pathologies. Overall test and specific dimensions scores were evaluated for each group. Results: Overall test and specific dimensions scores were significantly lower in patients with MO when compared to the CO and LRYGBP groups. There were no differences between the CO and LRYGBP groups in the overall score with regard to disease-specific digestive symptoms and the psychological and social dimensions. Conclusions: The quality of life of morbidly obese patients is worsened not only because of the presence of digestive symptoms but also because of their emotional, physical and social impact. Patients operated on by LRYGBP experience an improvement in their quality of life, with good tolerance of the anatomical changes.     

Vertical Isolated Gastroplasty with Gastro-enteral Bypass: Preliminary Results

Background: The authors present a new restrictive and malabsorptive operation for treatment of morbid obesity, called vertical isolated gastroplasty (VIG). Methods: From Feb 2004 to May 2005, 30 patients with BMI ≥40 kg/m² or >35 kg/m² with co-morbidities underwent VIG via laparoscopy or laparotomy. The technique consisted in creation of a gastric tube preserving pylorus, and a Roux-limb of 300 cm to the bypassed stomach with the division 30 cm distal to the ligament of Treitz. Excess weight loss (EWL), BMI, complications and co-morbidities were assessed. Results: BMI and average preoperative weight were 41.2 kg/m² and 110.7 kg, respectively. At 12 months postoperatively, BMI and average weight were 23.4 kg/m² and 65.1 kg, respectively, with EWL 90.2%. None of the patients presented dumping. Improvement in co-morbidities was >90%. Complications consisted of: 1 dehiscence of gastric sutureline, 1 hemoperitoneum, 1 gastroenterostomy ulcer, 1 anemia of undetermined cause, and 3 cholelithiasis. There was no mortality. Conclusion: VIG has thus far been safe and effective, with the same results as other bariatric operations. VIG has certain advantages, such as lack of dumping and lack of clinically significant stenosis of the gastroenterostomy, which can occur with other techniques. Because a duodenal bypass is not performed, it allows physiologic absorption of iron and diagnostic and/or therapeutic access to the ampulla of Vater.     

Intragastric Balloon for Preoperative Weight Reduction in Candidates for Laparoscopic Gastric Bypass with Massive Obesity

Background: Laparoscopic bariatric operations can be technically challenging in massively obese patients. The potential of the intragastric balloon for preoperative weight reduction was evaluated in candidates for laparoscopic Roux-en-Y gastric bypass (LRYGBP) with super obesity. Methods: From January 2004 to March 2005, 10 patients with super obesity who were potential candidates for LRYGBP were included in a prospective observational study. An intragastric balloon was placed endoscopically under general anesthesia. Patients were then followed by a multidisciplinary team until removal of the balloon after 6 months. Weight, BMI, and percent excess weight lost (%EWL) were monitored after 1, 3 and 6 months. Results: The 10 patients were all female with mean ± SD age of 33±11 years (range 17-51). Initial weight was 175±25 kg (range 135-223) and initial BMI was 64±7 kg/m² (range 59-78). After completion of 1, 3 and 6 months, weight, BMI, and %EWL reached respectively: 166±27 kg*, 165±27 kg*, and 169±26 kg*; 61.1±7.6 kg/m²*, 60.8±8.4 kg/m²*, and 61±8.2 kg/m²*; 9±5%, 10±7%, 7±6%. (*=P<0.01 vs preop). Conclusion: In potential candidates for LRYGBP with super obesity, preoperative placement of an intragastric balloon can reduce the excess weight by 10% within 3 months. Extending this period failed to improve these results further.     

Biliopancreatic Diversion for Treatment of Morbid Obesity: Experience in 50 Cases

Background: Biliopancreatic diversion (BPD) by Scopinaro's method is an operation advocated by some surgeons as an effective treatment for morbid obesity. Methods: Between February 1995 and April 1997 we performed BPD by Scopinaro's method on 50 patients with morbid obesity (23 males), average age 41.4 years (range 20-63 years), average body weight 135.08 kg (range 89-256 kg), mean body mass index (BMI) 50.65 kg/m² (range 37.01-81.56 kg/m²). Results: In all cases a gradual decrease in weight was obtained [mean BMI at 1 month: 44.8 kg/m², at 6 months (31 patients): 35.09 kg/m², at 1 year (23 patients): 31.36 kg/m², at 18 months (14 patients): 29.89 kg/m² and at 2 years (5 patients): 29.27 kg/m²]. At the same time a significant improvement in the pathological conditions associated with morbid obesity was observed. The patients were able to suspend oral antihypertensive and antidiabetic therapy as these parameters spontaneously returned to normal values by the sixth postoperative month; all cases showed a marked reduction in hypercholesterolemia and hypertriglyceridemia. Postoperative complications were: one death (2%) on the third day due to heart failure; two late intestinal occlusions (4%); one acute dilatation of the stomach (2%); one peritonitis caused by early dehiscence of the anastomosis (2%); five anastomotic ulcers (10%); two cases of protein malnutrition (4%). Conclusions: BPD by Scopinaro's method is a bariatric procedure which is technically complex. However is it safe and reproducible and it induces a substantial weight loss.     

Laparoscopic Roux-en-Y gastric bypass for recalcitrant gastroesophageal reflux disease in morbidly obese patients.

BACKGROUND AND OBJECTIVES: Gastroesophageal reflux disease (GERD) is commonly associated with morbid obesity (MO). Antireflux surgery has a higher failure rate in MO and addresses only one of the comorbidities present. This paper reviews the results of laparoscopic Roux-en-Y gastric bypass (LRYGBP) performed for recalcitrant GERD in MO. METHODS: Patients with recalcitrant GERD and a body mass index (BMI)>35 undergoing LRYGBP were included. LRYGB included crural repair, creation of a small gastric pouch (30 mL), and intestinal bypass (150 to 180 cm). All patients were followed in clinic and by telephone. RESULTS: From February 1999 to April 2001, 57 patients (51 F, 6 M) with a mean age of 43 (range, 22 to 67) and a median BMI of 43 underwent LRYGBP. Hiatal hernia or esophagitis, or both, were present in 48, Barrett's in 2. LRYGBP was possible in 52 patients; 5 required open conversion. The median hospital stay was 3 days. Complications included 1 leak, 1 pulmonary emboli, 2 reoperations for internal roux limb hernia, and 7 gastrojejunal strictures. At a mean follow-up of 18 months (range, 3 to 30), all patients report improvement or no symptoms of GERD and a mean weight loss of 40 kg (range, 16 to 70). Quality of life scores (SF-36) were above national norms for physical and mental components (median 55, norms=50). GERD-health related quality of life median score was <1 (scale, 0 to 45, 0=asymptomatic, 45=worse). CONCLUSION: LRYGBP was effective for recalcitrant GERD in MO. LRYGBP also led to weight loss and improvement in other comorbidites. Surgeons with minimally invasive expertise should consider LRYGBP for treatment of GERD in the morbidly obese.     

Histologic Studies of the Bypassed Stomach after Roux-en-Y Gastric Bypass in a Porcine Model

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is highly effective for morbid obesity. However, the long-term effects in the bypassed segments are unknown. The aim of this study is to evaluate gastrin and histologic changes in bypassed segments after LRYGBP. Methods: 10 50-kg pigs were subjected to LRYGBP. Preoperative weight and serum gastrin were compared with similar measures at 6 months postoperatively, when the pigs were euthanized. At necropsy, full-thickness gastric, duodenal, and jejunal biopsies were performed. Normal biopsies were obtained from a control group of 10 pigs. Results: 1 pig died at 3 months postoperatively because of an intestinal intussusception. In the remaining 9 pigs, weight increased after surgery from 52±2.2 kg to 55±1.9 kg. Serum gastrin was unchanged after surgery (mean 68.2 vs 68.3 pg/mL at 3 months and 61.7 pg/mL at 6 months). Histology showed no abnormalities from sections in all control pigs, and in 7 of the LRYGBP pigs as well. 1 LRYGBP pig was found to have hyperplastic duodenal glands, jejunal mucosa with mild chronic inflammation, and gastric mucosa with focal erosive gastritis. 1 LRYGBP pig had jejunal sections showing Peyer's patches. Conclusion: LRYGBP is not associated with gastrin changes and major histologic changes in the bypassed segments, at 6 months postoperatively in the porcine model.     

Laparoscopic reoperation for early complications of laparoscopic gastric bypass

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a popular operation for morbid obesity.Early complications can be treated successfully with a laparoscopic approach.We reviewed our experience with laparoscopic re-exploration in the early postoperative period. Methods: The initial 85 patients who underwent LRYGBP by two surgeons at a training hospital were reviewed. All patients who required re-exploration within the first 60 days postoperatively were considered. Results: Nine patients underwent ten laparoscopic explorations. Mean BMI was 50 kg/m². One patient underwent revision for proximal anastomotic obstruction at 58 days postoperatively. Three patients developed obstruction at the level of the transverse mesocolon secondary to cicatrix and required laparoscopic release of the scar tissue.Two patients required revision of the jejuno-jejunostomy. Internal hernia through the mesenteric defect at the level of the transverse mesocolon was the cause of bowel obstruction in two patients. One patient underwent lysis of adhesions between the left colon and the transverse mesocolon at 6 days postoperatively. One out of the ten laparoscopic re-explorations was negative for any findings. Eight patients recovered without further complications and one patient required endoscopic dilatations of the proximal anastomosis. Conclusion: In the course of treating morbid obesity with laparoscopic intervention, complications will arise. Laparoscopic exploration for early complications is a safe and feasible option.     

Egyptian Experience in Laparoscopic Adjustable Gastric Banding (Technique, Complications and Intermediate Results)

Background: Surgery can provide effective longterm treatment for morbid obesity. The purpose of this study is to present an Egyptian experience of laparoscopic adjustable silicone gastric banding (LASGB) as a safe and effective treatment. Methods: 108 morbidly obese patients having body mass index (BMI) > 40 kg/m² were studied. 26 patients had a BMI > 50 kg/m² and < 60 kg/m², while 21 patients had a BMI ≥ 60 kg/m².The procedure was performed through a 4 or 5 trocar technique. Results: Mean age was 32.3 years. Mean BMI was 48.9 kg/m2. All except two procedures were completed by laparoscopy. Mean hospital stay was 2.2 days. Mean BMI after 12 months was 37.2 kg/m² and after 24 months was 34.3 kg/m². Mean follow-up was 2.1 years and included 87 patients (81%). Complications included: gastric perforation (1), pleural injury (1), liver injury (1), port complications (6), periband sepsis (1) and slippage (3).There were no mortalities in this series. Conclusions: LASGB proved to be safe and effective for the treatment of morbid obesity in Egyptian patients.     

Obesity Surgery Results Depending on Technique Performed: Long-Term Outcome

Background  Many techniques have excellent results at 2 years of follow-up but some matters regarding their long-term efficacy have arisen. This is why bariatric surgery results must be analyzed in long-term follow-up. The aim of this study was to extend the analysis over 5 years, evaluating weight loss, morbidity, and mortality of the surgical procedures performed. Methods  This was a retrospective cohort study of the different procedures for morbid obesity practiced in our Department of Surgery for morbid obesity. The results have been analyzed in terms of weight loss, morbidity improvement, and postoperative morbidity (Bariatric Analysis And Reporting Outcome System). Results  One hundred twenty-five patients were operated on open vertical banded gastroplasty (VBG), 150 patients of open biliopancreatic diversion (BPD) of Scopinaro, 100 patients of open modified BPD (common limb 75 cm; alimentary limb 225 cm), and 115 patients of laparoscopic Roux-en-Y gastric bypass (LRYGBP). Mean follow-up was: VBG 12 years, BPD 7 years, and LRYGBP 4 years. An excellent initial weight loss was observed at the end of the second year of follow-up in all techniques, but from this time an important regain of weight was observed in VBG group and a discrete weight regain in LRYGBP group. Only BPD groups kept excellent weight results so far in time. Mortality was: VBG 1.6%, BPD 1.2%, and LRYGBP 0%. Early postoperative complications were: VBG 25%, BPD 20.4%, and LRYGBP 20%. Late postoperative morbidity was: protein malnutrition 11% in Scopinaro BPD, 3% in Modified BPD group, and no cases reported either in VBG group or LRYGBP group; iron deficiency 20% VBG, 62% Scopinaro BPD, 40% modified BPD, and 30.5% LRYGBP. A 14.5% of VBG group required revision surgery to gastric bypass or to BPD due to 100% weight regain or vomiting. A 3.2% of Scopinaro BPD with severe protein malnutrition required revision surgery to lengthen common limb to 100 cm. A 0.8% of LRYGBP required revision surgery to distal LRYGBP (common limb 75 cm) due to 100% weight regain. Conclusions  The most complex bariatric procedures increase the effectiveness but unfortunately they also increase morbidity and mortality. LRYGBP is safe and effective for the treatment of morbid obesity. Modified BPD (75–225 cm) can be considered for the treatment of superobesity (body mass index > 50 kg/m²), and restrictive procedures such as VBG should only be performed in well-selected patients due to high rates of failure in long-term follow-up.