Evaluation of the Radiological Gastric Capacity and Evolution of the BMI 2–3 Years After Sleeve Gastrectomy

Background  Sleeve gastrectomy is a restrictive procedure for treatment of obese patients with different body mass index (BMI) and presents good results in terms of a reduction of percentage of excess weight loss and BMI. There is no consensus which is the optimal technique regarding to the diameter of the gastric tube, but a capacity of 100–120 ml has been suggested. In this prospective study, we compare the gastric capacity evaluated with barium sulfate or computer-aided tomography (CAT) scan early and 24 months after operation compared to the changes in body weight and BMI reduction in a small group of 15 consecutive patients submitted to sleeve gastrectomy. Methods  Fifteen successive obese patients submitted to laparoscopic sleeve gastrectomy were included. They were studied in order to measure the residual gastric capacity with barium sulfate and CAT scan early (3 days) and late (2 years) after surgery. Results  The early postoperative gastric volume was 108 ± 25 ml (80–120 ml) and 116.2 ± 78.24 assessed with barium sulfate and CAT scan, respectively. The gastric capacity at the late control increased to 250 ± 85 and 254 ± 56.8 assessed with the same techniques. However, patients remained stable with a BMI close to 25 without regain of weight at least at the time of observation. Conclusions  Gastric capacity can increase late after sleeve gastrectomy even after performing a narrow gastric tubulization. It is very important to measure objectively residual gastric volume after sleeve gastrectomy and its eventual increase in order to determine the late clinical results and to indicate eventual strategy for retreatment.     

The benefits of standardizing the operative procedure for the assistant in laparoscopy-assisted gastrectomy for gastric cancer

Background and aim  Laparoscopy-assisted distal gastrectomy (LADG) has not yet been widely adopted for the treatment of gastric cancers because of the perceived complexity of the procedure. In addition to the proficiency of the operator, other factors could potentially be optimized to improve postoperative outcomes. The aim of this study was to evaluate a standardized operative procedure for assistants performing LADG. Materials and methods  Of 114 patients, 64 initially underwent conventional LADG (CLDG) and then 50 underwent standardized procedure (SLDG) in which the role of assistant in LADG was completely established. Parameters compared for the SLDG and CLDG groups were operation time, estimated blood loss, intra- or postoperative complications, preservation of the vagus nerve, and the number of pathologically examined lymph nodes. Results  The operation time for the SLDG procedure (mean ± SE, 229 ± 6 min) was shorter than for the CLDG procedure (261 ± 8 min; P < 0.002), and the estimated blood loss for SLDG (57 ± 7 ml) was less than for CLDG (108 ± 17 ml, P < 0.004). The celiac branch of the vagus nerve was preserved in 73% of SLDG patients compared with 52% of CLDG patients (P < 0.03). More lymph nodes were pathologically examined in SLDG patients (38.3 ± 1.5) than in CLDG patients (32.5 ± 1.8, P = 0.02). Conclusions  Standardization of the LADG procedure for assistants enabled a shorter operation time, reduced blood loss, a higher rate of vagus nerve preservation, and more accurate lymph node dissection.     

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.     

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.     

Laparoscopic Sleeve Gastrectomy with Minimal Morbidity Early Results in 120 Morbidly Obese Patients

Background  In recent years, laparoscopic sleeve gastrectomy (LSG) as a single-stage procedure for the treatment of morbid obesity is becoming increasingly popular. Of continuing concern are the rate of postoperative complications and the lack of consensus as to surgical technique. Methods  A prospective study assessment was made of 120 consecutive morbidly obese patients with body mass index (BMI) of 43 ± 5 (30 to 63), who underwent LSG using the following technique: (1) division of the vascular supply of the greater gastric curvature and application of the linear stapler-cutter device beginning at 6–7 cm from the pylorus so that part of the antrum remains; (2) inversion of the staple line by placement of a seroserosal continuous suture close to the staple line; (3) use of a 48 Fr bougie so as to avoid possible stricture; (4) firing of the stapler parallel to the bougie to make the sleeve as narrow as possible and prevent segmental dilatation. Results  Intraoperative difficulties were encountered in four patients. There were no postoperative complications—no hemorrhage from the staple line, no anastomotic leakage or stricture, and no mortality. In 20 patients prior to the sleeve procedure, a gastric band was removed. During a median follow-up of 11.7 months (range 2–31 months), percent of excess BMI lost reached 53 ± 24% and the BMI decreased from 43 ± 5 to 34 ± 5 kg/m². Patient satisfaction scoring (1–4) at least 1 year after surgery was 3.6 ± 0.8. Conclusions  The good early results obtained with the above-outlined surgical technique in 120 consecutive patients undergoing LSG indicate that it is a safe and effective procedure for morbid obesity. However, long-term results are still pending.     

Laparoscopic Sleeve Gastrectomy in Ethnic Obese Chinese

Background  The aim of this study was to evaluate the effectiveness and safety of laparoscopic sleeve gastrectomy (LSG) for the treatment of obesity in ethnic Chinese in Hong Kong. Methods  Seventy consecutive Chinese patients (49 females; mean age 34.7 ± 8.8 [range 18–56] years) received LSG for the treatment of obesity from May 2006 to Nov 2007 as a stand-alone procedure for weight reduction. Mean baseline body weight (BW) and body mass index (BMI) were 108.9 ± 22.1 kg (range 71.0–164.9 kg) and 40.7 ± 7.8 kg/m² (range 27.4–68.4 kg/m²), respectively. Outcome measures were collected and assessed in a prospective manner. Results  All procedures were performed laparoscopically with no conversion. There was neither mortality nor any postoperative complications that required reoperation. Major complication occurred in two patients (2.9%; esophagogastric junction [EGJ] leak and stomach tube stricture). Mean follow-up was 7.1 ± 5.0 months. Mean procedure time was 90.6 ± 39.4 min, and mean hospital stay was 3.8 ± 2.3 days. Mean BMI loss was 6.3 ± 2.5, 9.0 ± 3.4 and 12.3 ± 4.5 kg/m² at 3, 6, and 12 months. Mean percent of excess BW loss was 48.5 ± 28.4, 69.7 ± 31.7, and 63.5 ± 29.4 at 3, 6, and 12 months. Conclusion  LSG is safe and effective in achieving significant weight loss in obese ethnic Chinese patients.     

Revision of Failed Bariatric Procedures to Roux-en-Y Gastric Bypass (RYGB)

Bariatric surgery for morbid obesity has been established as an effective treatment method and has been shown to be associated with resolution of co-morbidities. Despite its success, some patients may require revision because of weight regain or mechanical complications. From September 2005 to December 2009, 42 patients underwent revisional Roux-en-Y gastric bypass (RYGB). All procedures were performed by one surgeon. Demographics, indications for revision, complications, and weight loss were reviewed. Thirty-seven patients were treated with laparoscopic (n = 36) or open (n = 1) RYGB after failed laparoscopic adjustable gastric banding. Four patient were treated with laparoscopic (n = 3) or open (n-1) RYGB after failed vertical banded gastroplasty, and one patient underwent open redo RYGB due to large gastric pouch. Conversion rate from laparoscopy to open surgery was 2.5% (one patient). Mean operative time was 145.83 ± 35.19 min, and hospital stay was 3.36 ± 1.20 days. There was no mortality. Early and late complications occurred in six patients (14.2%). The mean follow-up was 15.83 ± 13.43 months. Mean preoperative body mass index was 45.15 ± 7.95 that decreased to 35.23 ± 6.7, and mean percentage excess weight loss was 41.19 ± 20.22 after RYGB within our follow-up period. RYGB as a revisional bariatric procedure is effective to treat complications of restrictive procedures and to further reduce weight in morbidly obese patients.     

Laparoscopic Seromyotomy for Long Stenosis After Sleeve Gastrectomy with or Without Duodenal Switch

Background  Sleeve gastrectomy (SG) can be performed either as isolated (ISG), or with the malabsorptive procedure of duodenal switch (SG/DS). Among the postoperative complications, stenosis of the SG is relatively rare and only scarcely mentioned in literature. We report our experience in nine patients presenting a long stenosis, not eligible for endoscopic balloon dilation, and treated by laparoscopic seromyotomy after ISG or SG/DS. Methods  From March 2006 to January 2008, four patients after ISG (0.7%) and five patients after SG/DS (0.8%) were consecutively submitted to laparoscopic seromyotomy for long stenosis, not eligible for endoscopic balloon dilation. Dysphagia appeared after a mean time of 9.2 ± 2.6 months (ISG) and of 18.6 ± 13.2 months (SG/DS). Preoperative mean dysphagia frequency was 4 ± 0 (ISG) and 4 ± 0 (SG/DS). Gastroesophageal reflux disease (GERD) symptoms appeared as de novo in two patients of both groups. Barium swallow showed a stenosis at the upper part of the SG (2) and at the level of the incisura angularis (7). Gastroscopy evidenced a mean length of the stricture of 4.7 ± 0.9 cm (ISG) and of 5.2 ± 1.3 cm (SG/DS). The primary outcomes measure was stricture healing rate. Secondary outcomes measures included procedure time, peroperative, and postoperative complications, performance of barium swallow check, and GERD symptoms improvement. Results  There were no conversions to open surgery and no mortality. There was no peroperative gastric perforation, but one patient was converted into Roux-en-Y gastric bypass (ISG). Mean operative time was 153.7 ± 39.4 min (ISG) and 110 ± 6.1 min (SG/DS). One gastric leak was recorded postoperatively (ISG). Mean hospital stay was 7.6 ± 5.8 days (ISG) and 3.4 ± 0.8 days (SG/DS). Barium swallow check after 1 month was satisfied in all patients, and they were able to tolerate a regular diet. After a mean follow-up of 21 ± 5.6 months (ISG), the mean dysphagia score was reduced to 0.6 ± 0.9, and after a mean follow-up of 17.6 ± 10.5 months (SG/DS) to 0.8 ± 0.8. De novo GERD symptoms improved in two patients of both groups. Conclusion  Laparoscopic seromyotomy after SG for long stenosis is feasible, and efficient for the treatment of symptomatic dysphagia. It has a beneficiary influence on de novo GERD symptoms improvement. There is, however, the risk of postoperative leak. This paper has been presented at the XIII World Congress of International Federation for the Surgery of Obesity and Metabolic Disorders, Buenos Aires, September 24–27, 2008.     

Decompressive craniectomy for the management of patients with refractory hypertension: should it be reconsidered?

Summary. Summary.   Introduction: The management of refractory post-traumatic cerebral oedema remains a frustrating endeavor for the neurosurgeon and the intensivist. Mortality and morbidity rates remain high, despite refinements in medical and pharmacological means of controlling intracranial hypertension.   Method and Material: In this retrospective study we have evaluated the efficacy of decompressive craniectomy as a last resort therapy, from the data of nine patients with severe brain injury and delayed cerebral oedema (diffuse injury type III), treated between January 1997 and September 1999. The following parameters were considered: age, Glascow Coma Scale, injury severity, intracranial pressure, CT findings, pupil reaction/posturing. Follow-up period was over at least 2 years and outcome measured on the GOS.   Results: Patients have been operated on post-trauma median day 3, mean age 26±9, GCS 7±3.7, mean APACHE II 16±6.4, mean ISS 27.8±16.1, mean preoperative ICP 37.7±10.0, mean postoperative ICP 18.1±16.01. Seven patients have been operated by a frontotemporoparietal approach (six of them bilateral, one unilateral) and two patients have been operated on by a bilateral subtemporal approach. Mortality rates 22%, severe disability 11%, good recovery 66%.   Discussion: Patients with STBI, developing delayed intracranial hypertension caused by diffuse cerebral oedema, definitely benefit from craniectomy when current medical treatment has failed. The encouraging results of outcome in this and more recent studies, indicate the need for a multi-institutional randomized prospective study evaluating early indicators of raised ICP, timing, efficacy of treatment, operative technique and complications of decompressive craniectomy. Published online August 12, 2002     

Safety and Efficacy of Roux-en-Y Gastric Bypass to Treat Type 2 Diabetes Mellitus in Non-severely Obese Patients

The efficacy of Roux-en-Y gastric bypass (RYGB) to control type 2 diabetes mellitus (T2DM) has been demonstrated in morbidly obese patients. Surgical procedures primarily focused on T2DM control in patients with body mass index (BMI) < 35 kg/m² have shown to effectively induce remission of T2DM. However, only few reports have evaluated the safety and efficacy of RYGB in this group of patients. The aim of this study is to assess the safety and efficacy of RYGB in TD2M patients with BMI < 35 kg/m². All T2DM patients with BMI < 35 kg/m² and at least 12 months of follow-up who underwent laparoscopic RYGB were included. Safety of the procedure was evaluated according to mortality, need of reoperation/conversion, and complication rates. Metabolic parameters were evaluated at baseline and 6, 12, and 24 months after surgery. Thirty patients were included. Seventeen (56.6%) were women. Age, BMI, and duration of diabetes were 48 ± 9 years, 33.7 ± 1.2 kg/m², 4 ± 2.9 years, respectively. No mortality was observed. No conversion/reoperation was needed. Average length of stay was 3.2 ± 0.9 days. Early and late postoperative complications were observed in five (16.6%) and five (16.6%) patients, respectively. Twelve months after surgery, remission was observed in 25 of 30 patients (83.3%). After 2 years, remission was achieved in 13 of 20 patients (65%), and hemoglobin A1c decreased from 8.1 ± 1.8% to 5.9 ± 1.1% and homeostasis model assessment of insulin resistance from 5.7 ± 3.2 to 1.9 ± 0.8 after 12 months. RYGB is a safe and effective procedure to induce T2DM remission in otherwise not eligible patients for bariatric surgery. Evidence from prospective studies is needed to validate this approach.     

Self-closing Nitinol U-Clips for intracranial arterial microanastomosis: a preliminary experience on seven cases

Purpose  To report experience on the use of self-closing nitinol U-Clips for different types of intracranial arterial microanastomosis. Methods  We treated 7 patients (3 females and 4 males, age ranging from 25 to 68 yo) admitted from November 2005 to January 2008 to the Neurological Institute C. Besta of Milan. One patient had cerebral hypoperfusion and the others a complex intracranial aneurysm. In each patient a bypass procedure was completed by using self-closing Nitinol U-Clips for intracranial arterial microanastomoses. Results  The total time of temporary occlusion was 15.71 ± 4.386 min. Bypass patency was confirmed intraoperatively by near-infrared indocyanine green videoangiography and microdoppler in each patient. No spasm of the graft was encountered and immediate post-operative bypass patency was confirmed in 6/7 patients. The graft thrombosed in 1 patient with antiphospholipid syndrome. 1 patient died from a massive Subarachnoid Hemorrhage due to rupture of an aneurysm while waiting for an endovascular procedure. In the 5 patients at the last follow-up, long-term patency of the bypass was confirmed and no neurological deficits occurred related to the procedure. Conclusion  This is the first report of the use of U-Clips for intracranial microanastomosis. Our data indicated that it is a safe technique, reduces the time taken to perform an anastomosis and the risk of an ischemic complication. Further studies of the longer-term patency of bypass as performed with U-Clips are required. P. Ferroli and F. Acerbi equally contributed to the paper.     

One Thousand Consecutive Mini-Gastric Bypass: Short- and Long-term Outcome

There is growing evidence that mini-gastric bypass (MGB) is a safe and effective procedure. Operative outcome and long-term follow-up of a consecutive cohort of patients who underwent MGB are reported. The data on 1,000 patients who underwent MGB from November 2005 to January 2011 at an academic institution were reviewed. Mean age was 33.15 ± 10.17 years (range, 14–72), preoperative BMI was 42.5 ± 6.3 kg/m² (range, 26–75), mean preoperative weight was 121.6 ± 23.8 kg (range, 71–240), and 663 were women. Operative time and length of stay for primary vs. revisional MGB were 89 ± 12.8 min vs. 144 ± 15 min (p < 0.01) and l.85 ± 0.8 day vs. 2.35 ± 1.89 day (p < 0.01). No deaths occurred within 30 days of surgery. Short-term complications occurred in 2.7% for primary vs. 11.6% for revisionnal MGB (p < 0.01). Five (0.5%) patients presented with leakage from the gastic tube but none had anastomotic leakage. Four (0.4%) patients, all with revisionnal MGB, presented with severe bile reflux and were cured by stapling the afferent loop and by a latero-lateral jejunojejunostomy. Excessive weight loss occurred in four patients; two were reversed and two were converted to sleeve gastrectomy. Maximal percent excess weight loss (EWL) of 72.5% occurred at 18 months. Weight regain subsequently occurred with a mean variation of −3.9% EWL at 60 months. The 50% EWL was achieved for 95% of patients at 18 months and for 89.8% at 60 months. MGB is an effective, relatively low-risk, and low-failure bariatric procedure. In addition, it can be easily revised, converted, or reversed.     

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.     

Time-consumption risk of real-time ultrasound-guided internal jugular vein cannulation in pediatric patients: comparison with two conventional techniques

To assess the efficacy of three different methods for internal jugular vein (IJV) cannulation in pediatric patients, we conducted a review of patients undergoing cardiovascular surgery over an 11-year period, in which success rates for cannulation and time from induction of anesthesia to cannulation were evaluated. The success rate was better for real-time ultrasound guidance (USG: 90%) than for anatomic landmarks (AL: 76%) or audio-Doppler guidance (ADG: 74%) and the time required was greater for USG (35.0 ± 13.6 min) than for AL (26.7 ± 11.2 min) or ADG (29.2 ± 8.9 min). However, USG resulted in a higher success rate than the other methods with comparable procedure time for smaller-body-weight (<5 kg) patients. Thus real-time USG leads to the highest success rate for IJV cannulation but with a significant time delay, whereas it was the most useful without time delay for the smaller-body-weight subgroup.     

Total laparoscopic gastric mobilization for esophagectomy

Background and aims  The operative mortality and morbidity associated with esophageal surgery has been decreasing with advances in surgical techniques and equipment, however, postoperative complication remains a major cause of a potentially fatal outcome. We herein describe a new technique for esophagectomy by total laparoscopic gastric mobilization technique as a minimally invasive surgery. Patients and methods  Between April 2003 and August 2007, 36 patients who were suffering from esophageal cancer were surgically resected at Kochi Medical School. Operation-related parameters, mortality, postoperative complication, intubation time, and length of surgical intensive care unit in patients with total laparoscopic gastric mobilization for esophagectomy (the TLGM group, n = 16) were evaluated, compared to patients with ordinary thoraco-abdominal esophagectomy (the OPEN group, n = 20). Results  There was no mortality in the TLGM group and one hospital death in the OPEN group. Operation time of the OPEN group (506 ± 64 min) was significant shorter than that of the TLGM group (558 ± 67 min). The estimated intraoperative blood loss volume in patients of the TLGM group (496 ± 259 mL) was much smaller than those of the OPEN group (1,067 ± 566 mL). The intubation time and the intensive care unit stay in the TLGM group were much shorter than that in the OPEN group. Conclusions  Esophagectomy with regional lymphadenectomy combined with total laparoscopic gastric mobilization is a safe and beneficial opportunity for patients who underwent surgical procedure for esophageal cancer.     

Laparoscopic Sleeve Gastrectomy for Morbid Obesity with Intra-operative Endoscopic Guidance. Immediate Peri-operative and 1-year Results after 25 Patients

Laparoscopic sleeve gastrectomy (LSG) represents a promising alternative option for the surgical treatment of morbid obesity. Its standard technique includes the longitudinal division of the stomach along a bougie of varying diameter. We report in this retrospective study our experience with LSG being performed with the use of intra-operative endoscopy instead of the bougie. Twenty-five consecutive patients (18 women, seven men) with a mean age of 40.2 years and mean body weight of 152.1 kg were submitted to LSG with intra-operative endoscopy in our hospital. The mean preoperative BMI was 53.5 kg/m². There were no conversions. Mean operative time was 117.5 min. There was no morbidity or mortality. The mean loss of excess body weight (EBW) at 3 months post-op was 19 ± 1.8 kg, at 6 months was 28.6 ± 4.5 kg, and at 1 year post-op was 48.9 ± 3.7 kg (min 11–max 92). In other words the patients had lost 30 ± 5%, 45 ± 7.7%, and 60.8 ± 4.3% of their EBW, respectively. The mean excess body weight loss at the day of the last visit to our outpatient clinic was 52.3 ± 4.3 kg which corresponded to 66.4 ± 4.3% of the total excess weight. LSG with intra-operative endoscopic guidance is a safe and efficient alternative method to treat morbid obesity and is a viable option for surgical units familiar with endoscopic techniques.     

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.     

Early and Late Abdominal Bleeding After Roux-en-Y Gastric Bypass: Sources and Tailored Therapeutic Strategies

Bleeding is a potentially serious complication after Roux-en-Y gastric bypass (RYGB). Preventive measures and therapeutic strategies have not been adequately defined. We reviewed data on 742 consecutive patients treated at the University of California San Francisco to identify cases of early and late bleeding (less or greater than 30 days after surgery) after RYGB. Bleeding was defined as symptoms or signs of bleeding, associated with blood transfusion. We recorded patient characteristics, details of the operative technique, diagnostic approach, therapeutic strategies, and outcomes. Twenty-six patients (3.5%) had postoperative bleeding, which mostly occurred in the first 30 days postoperatively (N = 19). Hematocrit decreased significantly from preoperative values (−5.2 ± 3.1 without bleeding vs. −14.8 ± 4.7 with, p < 0.01). Type 2 diabetes was more prevalent in patients who had bleeding (58% vs. 32%, p = 0.03). No other patient characteristics or details of the operative technique were associated with different rates of bleeding. Therapeutic intervention other than transfusion was needed for seven patients with early bleeding (36.8%) and for all patients with late bleeding. Four patients with early bleeding required reoperation. Early bleeding source was intraluminal in four patients, intraperitoneal in five, and self-limited and of unknown location in ten. Late bleeding occurred on average at 62.6 months (range, 5 to 300 months) after index surgery, five patients required reoperation, and the source was always intraluminal. Bleeding after RYGB may be from various anatomic sites; details of the operative technique were not associated with different rates of bleeding, and therapy should be tailored to suspected location of bleeding.