Endoscopic Cervical Bariatric Surgery: Follow-up Study in a Porcine Model

BACKGROUND: The realisation of bariatric surgery has to date modified the digestive process solely through procedures within the abdominal cavity. However, endocrine surgeons have recently demonstrated the feasibility of a minimally invasive approach to the neck. In this study, we explored the feasibility, safety and weight progression of a bariatric procedure performed at the neck. METHODS: Eleven 40-50 kg Yorkshire pigs underwent endoscopic placement of an adjustable band to the cervical esophagus (ECB). Weight was monitored at postoperative days 15, 30, and after 7 weeks; weight progression was compared with an identical group of pigs who underwent a sham procedure. At autopsy, the surgical site was evaluated in a microscopic and macroscopic manner. RESULTS: Mean operating time was 66 +/- 5.76 min. All pigs tolerated the procedure well, except one subject that experienced food intolerance. The ECB group experienced significantly slower weight gain than the sham group (P = 0.005). Proper location of the band and absence of microscopic lesions at the esophageal wall were confirmed at autopsy and pathological examination. CONCLUSION: Bariatric surgery at the neck is feasible and produces effects on weight reduction. Further refinements and longer observation periods are required to propose this procedure as safe and effective alternative in humans.     

Revisional Bariatric Surgery

Background  Revisional surgery is required in a significant number of patients because of failure to lose weight, loss of quality of life, weight regain, or complications of the previous procedure. It has traditionally been associated with higher complication rates, and there appears to be no standardized surgical approach to revisional surgery. The aim of the study was to review the revisional procedures performed at St George Private Hospital and analyze the outcomes of the different types of revisional surgery. Methods   We performed a retrospective review of 75 patients who underwent revisional surgery between December 2003 and October 2007. Demographic, anthropometric, perioperative, and clinical follow-up data were collected, and statistical analyses were performed using SPSS version 14.0. Results  Sixty-six of the 75 patients were female. The mean age at the time of revision was 46.32 (22–68) years. Mean initial weight was 119.08 kg, and body mass index (BMI) was 43.42 kg/m². The lowest BMI and excess weight loss (EWL) recorded after primary surgery was 36.9% and 53.5%, respectively. At the time of revision, the mean EWL was 24.79. The EWL at 3 months and 6 months were 41.7% and 47.8%, respectively. Revision was performed laparoscopically in 51 patients and via laparotomy in 24 patients. There was no mortality in the cohort, but there were 17.3% minor and 4.0% major perioperative morbidities. Conclusion  Our study suggests that revision can be performed safely. Weight loss is satisfactory, and complications of the previous operations were all reversed. Furthermore, revisions may be done laparoscopically, including those who had previous open procedures.     

Insurance Coverage Criteria for Panniculectomy and Redundant Skin Surgery after Bariatric Surgery: Why and When to Discuss

A dramatic increase in bariatric surgery has increased the number of patients with redundant skin/large panniculus after massive weight loss. This is best treated by surgery; however, not all patients with redundant skin/panniculus get authorization from insurance providers. There are certain insurance coverage criteria for panniculectomy that need to be met by patients for approval. Our search also demonstrated that there are not established criteria/guidelines for different body parts such as inner arms and thighs other than the pannus amongst third-party payers. These cases are appraised individually by third-party payers based on presented signs and symptoms. It is of utmost importance that members of a bariatric team are knowledgeable on these guidelines and should be able to discuss if necessary; however, currently utilized criteria should be discussed with patients, preferably in pre-bariatric surgery phase, and ideally by a plastic surgeon. Advantages are several-fold and discussed in the article.     

Bariatric Surgery and Bariatric Psychology: Evolution of the Dutch Approach

Background Success of bariatric surgery is largely dependent on patients’ abilities to change their lifestyle and underlying psychosocial and behavioral factors; these factors should be carefully scrutinized. However, no consensus or guidelines exist for these evaluations. Materials and Methods To get a better understanding of the practice of bariatric surgery and bariatric psychology in The Netherlands and its evolution, a survey of bariatric surgery programs was conducted. Results Between 2000 and 2005, performance of bariatric surgery in The Netherlands has increased from 564 to more than 2,000 annually, mostly adjustable gastric banding. Most hospitals have a multidisciplinary selection process, and in 89% of the cases, a mental health specialist was involved. Conclusion Bariatric surgery in The Netherlands has increased tremendously; however, it is mostly limited to restrictive procedures, and there is no consensus regarding the psychological evaluation of patients.     

Hemorrhagic and Thromboembolic Complications after Bariatric Surgery in Patients Receiving Chronic Anticoagulation Therapy

Background Perioperative management of bariatric surgical patients receiving chronic anticoagulation requires an understanding of potential hemorrhagic and thromboembolic risks. The aim of this study is to evaluate hemorrhagic and thromboembolic complications in morbidly obese patients who are on oral anticoagulation treatment and subsequently undergo laparoscopic bariatric surgery. Methods The medical records of all laparoscopic Roux-en-Y gastric bypass (LRYGB) patients from June 2001 to March 2006 were retrospectively reviewed. In addition, data of patients who received chronic anticoagulation therapy with Coumadin and underwent laparoscopic Roux-en-Y gastric bypass was analyzed. Clinical parameters included length of hospitalization, hemorrhagic complications, thromboembolic complications, conversion rate, reoperation, and blood transfusion. Results During the study period, 1,700 consecutive patients underwent bariatric surgery for the treatment of morbid obesity. Of these, 21 patients were treated with chronic oral anticoagulation; 3 of the 21 (14%) had hemorrhagic complications: one patient had intraluminal hemorrhage and two patients had intraabdominal hemorrhage. Two patients required blood transfusion, and one patient underwent surgical reintervention. None of the 21 laparoscopic operations were converted to open procedures. There were no postoperative mortalities, and there were no thromboembolic events in this series. Conclusions Laparoscopic bariatric surgery can be performed relatively safely in morbidly obese patients who are treated with chronic oral anticoagulation. Even in the presence of bleeding, patients can be successfully treated without the need for reoperation.     

Meralgia Paresthetica Following Bariatric Surgery

Background: Two papers in the literature have described meralgia paresthetica following bariatric surgery. One author ascribed the cause of the condition to pressure from an abdominal retractor. We encountered 11 similar cases in our bariatric surgery practice, but do not use the retractor previously invoked as the cause of the problem. It seems likely that some other factor is involved. Methods: Retrospective chart review. Results: 11 patients were identified whose symptoms and clinical findings were consistent with meralgia paresthetica. There were 6 men and 5 women. Symptoms developed immediately following surgery in 8 cases, and resolved spontaneously within 3 months in 6 of these. Conclusions: Multiple causes have been described for meralgia paresthetica. It appears to be more common in obese patients. While extrinsic pressure from an abdominal retractor may play a role in some cases, other factors are clearly involved in the cases reported here.     

Metabolic Syndrome after Laparoscopic Bariatric Surgery

Background  Metabolic syndrome (MS) is common among morbidly obese patients undergoing bariatric surgery. The aim of this study was to assess the impact and predictors of bariatric surgery on the resolution of MS. Methods  Subjects included 286 patients [age 44.0 ± 11.5, female 78.2%, BMI 48.7 ± 9.4, waist circumference 139 ± 20 cm, AST 23.5 ± 14.9, ALT 30.0 ± 20.1, type 2 diabetes mellitus (DM) 30.1% and MS 39.2%] who underwent bariatric surgery. Results  Of the entire cohort, 27.3% underwent malabsorptive surgery, 55.9% underwent restrictive surgery, and 16.8% had combination restrictive–malabsorptive surgery. Mean weight loss was 33.7 ± 20.1 kg after restrictive surgery (follow up period 298 ± 271 days), 39.4 ± 22.9 kg after malabsorptive surgery (follow-up period 306 ± 290 days), and 28.3 ± 14.1 kg after combination surgery (follow-up period 281 ± 239 days). Regardless of the type of bariatric surgery, significant improvements were noted in MS (p values from <0.0001–0.01) as well as its components such as DM (p values from <0.0001–0.0005), waist circumference (p values <0.0001), BMI (p values <0.0001), fasting serum triglycerides (p values <0.0001 to 0.001), and fasting serum glucose (p values <0.0001). Additionally, a significant improvement in AST/ALT ratio (p value = 0.0002) was noted in those undergoing restrictive surgery. Multivariate analysis showed that patients who underwent malabsorptive bariatric procedures experienced a significantly greater percent excess weight loss than patients who underwent restrictive procedures (p value = 0.0451). Percent excess weight loss increased with longer postoperative follow-up (p value <0.0001). Conclusions  Weight loss after bariatric surgery is associated with a significant improvement in MS and other metabolic factors.     

Psychiatric Issues in Bariatric Surgery

In this study, 100 patients were evaluated prior to surgery to assess psychiatric status. The demographic anthropometric and psychological characteristics are described. Seventeen patients developed severe psychiatric complications and required hospitalization; the diagnoses which precipitated hospital admission were most commonly affective disorders (especially major depression with suicidal ideation). The only deaths in the sample of 100 occurred among the patients who required post-surgical psychiatric hospitalization. The hospitalized group was compared to a matched group drawn from the original 100 patients. Factors associated with post-surgical psychiatric hospitalization were: presurgical psychiatric hospitalization, presence of multiple pre-surgical Axis I psychiatric diagnoses, and untreated Axis I diagnosis at the time of pre-surgical assessment. Psychiatric screening criteria were revised and 31 subsequent patients were evaluated; less than half of this group were found suitable for surgery at the time of preliminary assessment.     

The SAGES Bariatric Surgery Outcome Initiative

Background The recent initiative for identifying centers of excellence in bariatric surgery calls for documentation of surgical outcomes. The SAGES Outcomes Initiative is a national database introduced in 1999 as a method for surgeons to accumulate and compare their data with summary national data. A bariatric-specific dataset was established later in 2001. The aim of this study was to compare the outcomes of bariatric surgery from the Society of American Gastrointestinal Endoscopic Surgeons’ (SAGES) bariatric database with data derived from a national administrative database of academic centers. Methods Between 2001 and 2004, 24 surgeons with 1,954 patients participated in the SAGES Bariatric Outcome Initiative, and 97 institutions with 42,847 patients participated in the University HealthSystem Consortium (UHC) database. Only 7 of the 24 surgeons participating in the SAGES Bariatric Outcome Initiative submitted more than 50 cases. The main outcome measures included demographics, comorbidities, type of bariatric procedure, operative time, length of hospital stay, short- and long-term complications, mortality, and weight loss. Results Both datasets were comparable for gender. Roux-en-Y gastric bypass had been performed for 88% of the patients in the SAGES database and 96% of the patients in the UHC database. Associated comorbidities were similar between the two groups except for a higher rate of hyperlipidemia for the patients in the SAGES database. The SAGES database contains more bariatric-specific information such as body mass index, operative time, blood loss, bariatric-specific complications, long-term complications, and weight loss data than the UHC database. According to the available data, no statistically significant differences exist between the two datasets in terms of perioperative complications and mortality. Conclusions The SAGES Bariatric Outcome Initiative provides valuable bariatric-specific data not currently available in an administrative database that may be useful for benchmarking purposes. However, this database is currently underutilized. Presented at the Annual 2005 Meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Hollywood, FL, USA, 14 April 2005     

单切口经脐腹腔镜减重手术

目的近来,人们将单一切口腹腔镜胃减重手术的方法,视为除经自然腔道内镜手术之外的另一种选择。单一切口经脐腹腔镜胃减重手术的优势在于能隐藏手术瘢痕,获得较好的美容效果。然而,由于器械操作空间有限及肝脏牵引困难,此项技术一直受到很大限制,仅被认为适用于简单胃减重手术。本研究中,通过采用特殊技术和操作以期改善手术的安全及有效性,使其应用于更广泛的领域。方法自2008年12月起,我院采用LST装置（liver-suspension tape）及′Ω形脐孔成形术成功开展单一切口经脐胃减重手术。至2009年7月,共完成40例患者45例次手术,包括5例次胆囊切除术,2例胃束缚带放置,6例次胃袖状切除,32例次Roux-en-Y胃转流术（Roux-en-Y gastric bypass,RYGB）,记录术后住院天数及并发症情况。结果平均手术时间89.9min,平均术后住院1.15d。无一例发生术中或术后并发症,无死亡病例。所有病人均满意手术的美容效果。结论采用本技术施行单一切口经脐胃减重手术是安全、可行的,有进一步推广应用于更多外科手术的价值。     

An Occasional Review of Bariatric Surgery on the Internet

This is a brief evaluation of web sites available on the Internet. Particular emphasis has been placed on those which provide information concerning the indications, benefits, risks and outcome of surgery for obesity. These web sites are suitable for use as informational sources for potential candidates for surgery for obesity.     

Psychological Evaluation of Bariatric Surgery Applicants: Procedures and Reasons for Delay or Denial of Surgery

Background Psychologists play an important role as members of the bariatric surgery team. The current investigation examined the frequency with which psychologists recommend delay or denial of surgery for psychological reasons, the procedures they use in making their clinical decisions, and the reasons for such conclusions. Method A sample of 103 psychologists with experience in conducting pre-surgical psychological evaluations responded to a brief survey. Results There was significant variability in the number of evaluations psychologists complete and the instruments they use to make their clinical decisions. For most candidates, the evaluation results in psychological clearance for surgery. However, approximately 15%, on average, are delayed or denied for psychological reasons. The most common reasons for delaying or denying surgery were significant psychopathology (including psychosis or bipolar disorder), untreated or undertreated depression, and lack of understanding about the risks and postoperative requirements of surgery, which were reported by 51, 39, and 30% of respondents, respectively. Several other reasons were reported less frequently and many appeared to be idiosyncratic. Conclusion Psychologists differ in their preoperative evaluation practices. Further research is needed to determine the reasons for the variability in clinical decision making and the long-term medical and psychosocial outcomes associated with the recommendation to delay or deny surgery for psychosocial reasons. When patients receive such a recommendation, they can be encouraged to seek a second opinion from a mental health professional with bariatric expertise.     

Band and Port-Related Morbidity After Bariatric Surgery: An Underestimated Problem

Objective

To evaluate the magnitude of the morbidity related to the system used for gastric banding Methods Between January 1997 and December 2004, 286 consecutive patients underwent laparoscopic gastric banding (LAGB) in one center. We used 4 models of LapBand® 9.75, 10, 11 and Vanguard with pars flacida route. Recalibration of band was performed in our consultation unit without systematic radiologic control. We considered four kinds of complication: port displacement, port rupture, band rupture and others problems.

Results

The mean follow up was 3.3±2.8 years with a median 2.9 years. Complications occurred within a mean time of 2.2±1.9 years. For the models vanguard and size 11, there were no rupture and 15 (27.7%) displacements whereas for size 9.75 and 10 there were 39 ruptures (14.7%) and 15 (5.6%) displacements. Types of complications were related to the bands used i.e. more port displacements for the models vanguard and size 11and more band and port ruptures for the models size 9.75 and 10. But when we considered the respective follow up according to the type of band these differences were no longer significant. Moreover rupture rate was significantly high but decreased after March 2002 because of changing of junction between port and catheter. Mean excess weight loss (35.2±27.7%) was not different in group whether the patients were reoperated or not.

Conclusion

Band and port related morbidity is an important aspect of bariatric surgery. We have to pay attention to material evolution and to our follow up for calibration. Some new recent technical advancement could improve the management of these patients.

     

Histological Alterations Following Bariatric Surgery: Pilot Study

Background  Macroscopic clinical evidence of tissue damaging following bariatric surgery pushed plastic surgeons to presume microscopic alterations as well. Methods  Five preliminary cases studied randomly, and compared with healthy tissues, confirmed these initial suspects. A deeper and wider study has then been structured. Results  Preliminary results are so evident to encourage us to carry on an estimated 2–3 years multidisciplinary study. Conclusions  What we want to study is if histological post-bariatric alterations are confirmed, and if these can be considered responsible for higher complication rate in body contouring following bariatric surgery.     

Psychological Gender Differences in Bariatric Surgery Candidates

Background Over 177,000 bariatric surgeries were performed in 2006. Most patients are required to receive presurgical psychological clearance, although there are no empirically validated psycho-surgical risk factors. In an effort to establish normative data on suspected risk factors, the present study was conducted to determine if males and females differ on psycho-surgical risk factors. Methods Subjects consisted of 361 consecutive bariatric surgery candidates undergoing a psychological evaluation in a private practice setting. They were administered the PsyBari, a test that detects and measures psycho-surgical risk factors, and the Beck Depression Inventory (BDI-2). Results The results indicate that males have significantly higher BMIs than females (p = 0.035). Females have tried significantly more diets than males (p < 0.000). Females are significantly more likely to report a history of depression than males (p < 0.000). Females received significantly higher scores on the PsyBari Depression Index than males (p < 0.000.). Females received significantly higher BDI-2 scores than males (p < 0.001). Females are significantly more likely to report a history of anxiety than males (p = 0.004). Females received significantly higher scores on the PsyBari Social Anxiety Index than males (p = 0.038). Conclusion The results indicate that males and females differ significantly on suspected psycho-surgical risk factors. Assessments of bariatric surgery candidates should recognize that males and females have different baselines for psycho-surgical risk factors. Further research on bariatric surgery candidates should report results separated by gender.