Gastric surgery for morbid obesity. Complications and long-term weight control

The efficacy of gastric surgery for morbid obesity has often been questioned because of incomplete long-term patient follow-up. Between 1977 and 1984, 537 consecutive patients received either a gastric bypass with a Roux-en-Y gastrojejunostomy, an unbanded gastrogastrostomy, or a vertical banded gastroplasty. The follow-up period was 5 years for all patients who underwent Roux-en-Y gastrojejunostomy and unbanded gastrogastrostomy and 3 years for all patients who underwent vertical banded gastroplasty. Only 5.8% of all patients were unavailable for this late follow-up. The unbanded gastrogastrostomy was not an effective weight-control operation. Both the Roux-en-Y gastrojejunostomy and vertical banded gastroplasty provided effective long-term weight control. Although the Roux-en-Y gastrojejunostomy gave slightly better weight control than the vertical banded gastroplasty, the more simple, safe, and physiological vertical banded gastroplasty is the procedure of choice for most patients with morbid obesity.     

Modified vertical banded gastroplasty as revision of failed high gastric reduction for morbid obesity

Vertical banded gastroplasty is currently closest to the ideal gastric restrictive procedure for the surgical treatment of obesity. A modification of the technique of vertical banded gastroplasty can be successfully used to revise a failed high gastric reduction for morbid obesity.     

MODIFIED VERTICAL BANDED GASTROPLASTY AS REVISION OF FAILED HIGH GASTRIC REDUCTION FOR MORBID OBSEITY

Vertical banded gastroplasty is currently closest to the ideal gastric restrictive procedure for the surgical treatment of obesity. A modification of the technique of vertical banded gastroplasty can be successfully used to revise a failed high gastric reduction for morbid obesity.     

Prospective randomised comparison of adjustable gastric banding and vertical banded gastroplasty for morbid obesity.

OBJECTIVE: To compare the clinical results of adjustable gastric banding and vertical banded gastroplasty for morbid obesity. DESIGN: Prospective randomised trial. SETTING: University hospital, Sweden. PATIENTS: 59 morbidly obese patients, listed for obesity surgery. INTERVENTIONS: Adjustable gastric banding (n = 29) or vertical banded gastroplasty (n = 30). MAIN OUTCOME MEASURES: Weight loss, complications, need for revisional surgery, reflux symptoms and the patient's own evaluation. RESULTS: Five years after surgery the mean (SEM) weight reduction for adjustable gastric banding was 43 (3.0) kg and for vertical banded gastroplasty 35 (4.8) kg. One patient in each group died of unrelated causes during follow-up and 3 and 2 patients, respectively, were lost to follow-up. One patient in the vertical banded group required reoperation for an anastomotic leak on the third postoperative day. A total of 3 patients in the adjustable group required reoperation and 11 in the vertical banded group. CONCLUSIONS: Adjustable gastric banding carries a smaller risk of reoperation than vertical banded gastroplasty and the weight reduction is in the same order of magnitude.     

Obesity surgery in patients suffering from monogenetic adipositas

Surgical treatment of patients suffering from monogenetic forms of morbid obesity is considered to be the poorest investigated theme in bariatric surgery. This review article presents aspects of genetic disorders in morbid obesity as well as some aspects of surgical treatment in patients with monogenetic forms of morbid obesity (Prader-Willi-Syndrome). Gastric restrictive procedures such as vertical banded gastroplasty or adjustable gastric banding as well as malabsorptive and mix procedures such as biliopancreatic diversion or Roux-en-Y gastric bypass are used for treatment, similar to polygenetic forms of morbid obesity. Until to now there is no evidence-based data because of the small number of published cases. Decisions about the indication to operation and about the choice of surgical procedures are based on the empiric fundament. It is to suggest that the use of growth hormones in patients with monogenetic forms of morbid obesity could positively influence the results of bariatric surgery in these patients.     

Bariatric Surgery: Asia-Pacific Perspective

Background: There is a world-wide epidemic of overweight, obesity and morbid obesity. Bariatric surgery today, as the only effective therapy for morbid obesity, is expanding exponentially to meet the global epidemic of morbid obesity. Bariatric surgeons in the Asia-Pacific region had founded the Asia-Pacific Bariatric Surgery Group (APBSG) at Seoul, Korea on October 6, 2004. Methods: E-mail requests for information were sent to the national bariatric surgery leaders. These requests were followed, if necessary, by second e-mail requests and communications seeking clarification. The summary data was also discussed at the 1st Asia-Pacific Bariatric Consensus Meeting held in Taipei, February 27, 2005. Results: 11 countries or areas in Asia had started bariatric surgery and responded to the general questions. In 2004, 636 bariatric operations were performed by 61 bariatric surgeons. The earliest data for starting bariatric surgery was in 1974 in Taiwan. Following the development of gastric partition, Taiwan performed the first case in 1981, Japan in 1982 and Singapore in 1987. In 2004, 11 countries have started bariatric surgery. The APBSG was founded in 2004. In 2004, 12.1% of operations were open and 87.9% laparoscopic. The 6 most popular operations were: laparoscopic adjustable banding 42.3%; laparoscopic gastric bypass 34.2%; open vertical banded gastroplasty 7.5%; laparoscopic vertical banded gastroplasty 6.3%; laparoscopic sleeve gastrectomy 6.3%; open gastric bypass 4.2%. Pooling open and laparoscopic procedures, relative percentages were gastric banding 42.3%; gastric bypass 38.4%; vertical banded gastroplasty 13.8%. The APBSG consensus meeting recommended bariatric surgery in Asian patients with BMI >37 or >32 with diabetes or two other obesity-related co-morbidities. Conclusions: Bariatric surgery is expanding rapidly in Asia to meet rapidly increasing obesity. The modification of the indications for bariatric surgery in the Asian is proposed.     

A case of Pickwickian syndrome with improvement of obesity-related sleep apnea following vertical banded gastroplasty

The patient was 22-year-old male who had suffered from hypermotility during sleep and excessive daytime sleepiness, and 270% in excess body weight. Values of arterial blood gas analysis during sleep were 65mmHg in PaCO2 and 19mmHg in PaO2. He was diagnosed as morbid obesity with Pickwickian syndrome and underwent vertical banded gastroplasty. His body weight decreased from 170kg to 113kg four months after surgery and 107kg one year after surgery. The whole-night polyhypnographic sleep study was performed before and after operation and showed dramatic improvement of apnea index which was calculated by dividing the number of apneas by the total sleep time. We analyzed 199 case reports which had noted symptoms of Pickwickian syndrome between 1963 and 1989 in Japan. In many reported cases, body weight decreased transiently but returned to the level before medical treatment. Under these considerations, gastroplasty is a beneficial surgical treatment for the morbid obesity with Pickwickian syndrome.     

Laparoscopic surgery for obesity

Bariatrics surgery has been a subject to a noteworthy revolution since the advent of the laparoscopic approach. This overview of the literature highlights on established scientific data in this field and the eventual evidence bases of laparoscopic surgery. Vertical banded gastroplasty and gastric bypass are now recognised as the gold-standards for the surgical treatment of morbid obesity by laparotomy. For the minimally invasive approach, the gastric banding appears now as a validated technique with a good level of evidence. The results of this approach appears to be comparable to those of other techniques (in terms of weight loss). But there is at present no randomized trial comparing the gastric banding with the gold-standards (gastric banding versus vertical banded gastroplasty). Some particular feature of this surgery are discussed (such as the association of a gastroesophageal reflux disease or a cholelithiasis). The criteria of patient's selection, the pre and post-operative management are also detailed in the light of literature data and guidelines of international societies.     

Bariatric Surgery Worldwide 2003

Background: There is a world epidemic of overweight, obesity, and morbid obesity, encompassing 1.7 billion people. Bariatric surgery today is the only effective therapy for morbid obesity. Methods: E-mail requests for information were sent to the presidents of the national societies of the 31 International Federation for the Surgery of Obesity (IFSO) nations, or national groupings, plus Sweden. Responses were tabulated; calculation of relative prevalence of specific procedures was done by weighted averages. Results: Responders were 26 of 32 (81%) for the general questions and 24 of 32 (75%) for the question on specific operative percentages. In the year 2002-2003, 146,301 bariatric surgery operations were performed by 2,839 bariatric surgeons; 103,000 of these operations were performed in USA/Canada by 850 surgeons. The earliest start date for bariatric surgery was 1953 in the USA; IFSO was founded in 1995. In the year 2002-2003, 37.15% of operations were open; 62.85% laparoscopic. The 6 most popular procedures by weighted averages were: laparoscopic gastric bypass, 25.67%; laparoscopic adjustable gastric banding, 24.14%; open gastric bypass, 23.07%; laparoscopic long-limb gastric bypass, 8.9%; open long-limb gastric bypass, 7.45%; and open vertical banded gastroplasty, 4.25%. Pooling open and laparoscopic procedures, relative percentages were: gastric bypass, 65.11%; gastric banding, 24.41%; vertical banded gastroplasty, 5.43%; and biliopancreatic diversion/duodenal switch, 4.85%. Categorizing into restrictive/malabsorptive, purely restrictive, and primarily malabsorptive, the relative distribution of procedures was 65.11%, 29.84%, and 4.85%, respectively. The number of countries performing gastric banding was 23 (95%), gastric bypass 21 (88%), vertical banded gastroplasty 19 (79%), and biliopancreatic diversion/duodenal switch 16 (67%). Purely restrictive procedures were performed in 24 (100%) of the countries, restrictive/malabsorptive in 21 (88%), and primarily malabsorptive in 18 (75%). Conclusions: Bariatric surgery is expanding exponentially to meet the global epidemic of morbid obesity. Operative procedures in bariatric surgery are in flux and specific geographic trends and shifts are evident. Yet, of the patients qualifying for surgery, only about 1% are receiving this therapy – the only effective treatment currently available.     

The state of the art in bariatric surgery for weight loss in the morbidly obese patient

Bariatric surgery is a safe and effective method for achieving durable weight loss for patients with morbid obesity. Gastric restrictive procedures include vertical banded gastroplasty and gastric banding. Malabsorptive procedures include long-limb gastric bypass, biliopancreatic diversion, and biliopancreatic diversion with duodenal switch. The gastric bypass has features of both restriction and malabsorption. The laparoscopic approach to bariatric surgery has substantially improved postoperative recovery. Careful patient selection and preoperative work-up are extremely important. A number of medical comorbidities are improved after surgically-induced weight loss.     

Laparoscopic vertical banded gastroplasty

Background The commonest surgical procedure for management of morbid obesity in Europe is laparoscopic adjustable gastric banding (LAGB), even though laparoscopic vertical banded gastroplasty (LVBG) is still considered to be a gold standard restrictive option in bariatric surgery. A multicenter prospective study was designed to to assess the efficacy of LVBG in terms of weight loss and complication rates for obese patients who have indications for a restrictive procedure. Patients and methods Two-hundred morbidly obese patients (84.5% female) with a mean age of 41 years and mean body mass index (BMI) of 43.2 kg/m² underwent LVBG as described by MacLean. Five trocars were placed in standard positions as per laparoscopic upper gastrointestinal surgery. A vertical gastric pouch (30 ml) was created with circular (21 or 25mm) and endolinear stapling techniques, enabling definitive separation of the two parts of the stomach. The gastric outlet was calibrated with either a polypropylene mesh (5.5 cm in length and 1cm in width) or a nonadjustable silicone band. The median follow-up period was 30 months (range, 1–72 months). Results One case had to be converted to open surgery (gastric perforation) and there was one death secondary to peritonitis of unknown etiology. The morbidity rate was 24%, comprising the following complications: gastric outlet stenosis (8%); staple line leak (2.5%); food trapping (1.5%); peritonitis (1%); thrombophlebitis (1.5%); pulmonary embolism (0.5%); and gastroesophageal reflux (9%). The excess weight loss achieved was 56.7% (1 year), 68.3% (2 years), and 65.1% (3 years). Conclusions Laparoscopic vertical banded gastroplasty is an effective procedure for the surgical management of morbid obesity, especially for patients who present hyperphagia but are unable to manage the constraints of adjustable gastric banding. Laparoscopic vertical banded gastroplasty is safe, as demonstrated by an acceptable complication rate, of which gastric outlet stenosis, staple line leakage, and gastroesophageal reflux predominate.     

Weight loss with vertical banded gastroplasty and Roux-Y gastric bypass for morbid obesity with selective versus random assignment

In a previous study, Roux-Y gastric bypass was found to be significantly more effective than vertical banded gastroplasty for weight loss in morbid obesity, especially for patients addicted to sweets, probably as a result of dumping syndrome symptoms. This study evaluated the ability to selectively assign nonsweet eaters to vertical banded gastroplasty and sweet eaters to gastric bypass. Compared with random assignment, the percentage excess weight lost at 2 years improved significantly with both groups combined. In the vertical banded gastroplasty group, the percentage increased from 41 +/- 19 to 55 +/- 19 percent. With selective assignment, the percentage excess weight lost with gastric bypass was still better than that with vertical banded gastroplasty. Weight loss with gastric bypass was still superior to that of vertical banded gastroplasty but at the expense of more complications. Gastric bypass was ineffective in 19 percent of the super obese patients. A combined restrictive, malabsorptive procedure may be necessary in such persons.     

Conversion surgery for morbid obesity: complications and long-term weight control

Some operations for morbid obesity fail--for a variety of reasons. To better understand the risk and efficacy of converting, during a single operation, a failed procedure to a second type of operation for morbid obesity, a review was made of all 120 patients who underwent this type of conversion surgery at one university hospital during a 10-year period. The initial operations of 62 patients were converted to a gastric bypass with a Roux-en-Y gastrojejunostomy, 11 to an unbanded gastrogastrostomy, and 47 to a vertical banded gastroplasty. Four patients are dead (three of unrelated causes), 11 have undergone a third operation for morbid obesity, and five (4.2%) are lost to follow-up. For 69 of 86 patients, 3- to 5-year follow-up data are available. Serious early complications occurred in 5.8% of the patients. Almost 80% of the patients who received an unbanded gastrogastroplasty did not control their weight, whereas most of those who received a Roux-en-Y gastrojejunostomy or a vertical banded gastroplasty had satisfactory long-term weight control 3 to 5 years later, maintaining an average weight loss of 30% of their original weight or 55% of their excess weight. Conversion surgery is safe and effective.     

Gallstone formation prophylaxis after gastric restrictive procedures for weight loss: a randomized double-blind placebo-controlled trial

OBJECT: To determine if a 6-month regimen of prophylactic ursodeoxycholic acid is effective in the prevention of gallstones. SUMMARY BACKGROUND DATA: Rapid weight loss after surgery for the treatment of morbid obesity is associated with a high incidence of gallstone formation. METHODS: Patients with vertical banded gastroplasty (VBG) and adjustable gastric banding (AGB) were enrolled in this study. A single-center, randomized, double-blind, prospective trial evaluated 500 mg of ursodeoxycholic acid versus placebo, beginning within 3 days after surgery and continuing for 6 months or until gallstone development, for patients with morbid obesity. Transabdominal sonography or abdominal CT scan was obtained preoperatively at 3, 6, 12, and 24 months after surgery or until gallstone formation. RESULTS: From March 1997 to April 2000, 262 patients were submitted to surgery. Seventy-seven patients refused to participate in the study; 43 patients with previous gallstone operation or verified gallstones preoperatively were excluded. Of 152 patients, 76 were randomized to placebo and 76 to 500 mg of ursodeoxycholic acid daily. Preoperative age, sex, weight, BMI, and postoperative weight loss were not significantly different between groups. Gallstone formation was significantly less (P = 0.0018, Fisher exact test) frequent with ursodeoxycholic acid than with placebo at 12 months, 3% versus 22%, and 8% versus 30% (P = 0.0022) at 24 months, cholecystectomy in 4.7% versus 12%, respectively (P < 0,02, Fisher exact test). CONCLUSION: A daily dose of 500 mg of ursodeoxycholic acid for 6 months is effective prophylaxis for gallstone formation following gastric restrictive procedures.     

Vertical Banded Gastroplasty for Sleep Apnea Syndrome Associated with Morbid Obesity

We report a case of morbid obesity accompanied by obstructive sleep apnea syndrome (SAS) and obesity hypoventilation syndrome (OHS). Satisfactory weight control was obtained without significant surgical complications after vertical banded gastroplasty. With the reduction in weight, the symptoms of SAS and OHS, as well as several other complications caused by the severe obesity, disappeared. Quality of life also improved remarkably, as exhibited by improved activity performance and disappearance of irritability at waking. Thus, it appears that vertical banded gastroplasty is efficacious in the treatment of morbid obesity with sleep apnea and hypoventilation.     

Laparoscopic Roux-en-Y gastric bypass for morbid obesity.

Surgery is currently the only effective treatment for morbid obesity. The two most commonly accepted operations are the Roux-en-Y gastric bypass and vertical banded gastroplasty. Although multiple authors have reported on a laparoscopic approach to gastric banding, the Roux-en-Y gastric bypass is a complex operation to be replicated using laparoscopic techniques. In this article, we describe our technique of the Roux-en-Y gastric bypass using a laparoscopic approach in four cases.     

Laparoscopic adjustable silicone gastric banding

Laparoscopic adjustable silicone gastric banding (LASGB) is a relatively new surgical procedure for the treatment of morbid obesity The most popular banding procedure is the vertical banded gastroplasty, however, there are risks involved in this procedure, including staple-line disruption and postoperative intractable vomiting. This article presents the advantages of using the LASGB device over former types of gastric banding.     

The Influence of Dumping on Weight Loss After Gastric Restrictive Surgery for Morbid Obesity

Background: The dumping syndrome that follows Roux-en-Y gastric bypass for morbid obesity is considered to be the primary mechanism of improved weight loss as compared with the purely restrictive vertical banded gastroplasty. To evaluate the influence of dumping on post-operative weight loss, severity of dumping was determined using Sigstad's clinical diagnostic index. Methods: One hundred and thirty seven gastric bypass and 19 gastroplasty patients were assessed 18-24 months following surgery. Sigstad's criteria for the dumping syndrome were met by 75.9% of gastric bypass and no gastroplasty patients. Among gastric bypass patients, no relationships were found between severity of dumping and weight loss, as measured by per cent of excess body weight loss or change in body mass index. Weight loss was significantly greater with gastric bypass than gastroplasty patients (72.5 compared to 47.9% of excess body weight loss). All gastroplasty and 24.1% of gastric bypass patients were classified as nondumpers. The difference in weight loss between surgical procedures was not related to dumping: gastric bypass non-dumpers lost significantly more weight (69.1% excess body weight loss) than gastroplasty patients. Conclusions: This study fails to demonstrate a significant relationship between dumping severity and weight loss. It is inferred that the superior weight loss of gastric bypass compared to gastroplasty has some other etiology.     

Placement of the GaBP Ring System in the Banded Gastric Bypass Operation

Currently, bariatric surgeons fashion the band or ring reinforcement prosthesis, to control the stoma in the vertical banded gastroplasty and gastric bypass operations for morbid obesity. To meet this need, the GaBP Ring system has been developed in various sizes, and consists of 4 main parts to provide a means for inserting a ring around the gastric pouch in the banded gastric bypass or the vertical banded gastroplasty. The pre-manufactured and sterilized device provides for better standardization and quality control than individually surgeon-fashioned devices. The GaBP Ring system is described, and the technique of placement and the pertinent initial clinical results are presented.     

Complications after gastroplasty and gastric bypass as a primary operation and as a reoperation

Background: Since 1991 we performed vertical banded gastroplasty (VBG) as our surgical treatment of choice for morbid obesity in 680 patients, and since 1996 we also performed Roux-en-Y gastric bypass (RYGB) in 36 patients. For revisional surgery, the surgeons chose procedures based on their experience. Methods: We recorded early complications (0.6%) and late complications (8.5%) after the primary operations.When staple-line disruption or stenosis of the banded stoma occurred after VBG, revisional surgery was performed with re-VBG or conversion to RYGBP. Some early complications needed emergency operation for bleeding or gastric perforation. Results: Mortality was zero. Reoperation with reVBG and RYGBP was effective in all patients, but for many, a long stay in hospital was necessary because reoperation had a high rate of early and late complications, 33.8% and 21.8% respectively. Conclusion: The treatment of complications after VBG with re-VBG and RYGBP had danger.We believe that when VBG failure occurs, to avoid dangerous complications again, we should perform a biliopancreatic diversion, which does not involve a gastric restriction.