The Effect of Surgical Weight Reduction on Functional Status in Morbidly Obese Patients with Low Back Pain

Background: Although low back (LBP) pain is not a lifethreatening disease, it is a source of significant discomfort and disability and accounts for work absences. It has been shown previously that morbid obesity is associated with increased frequency of LBP and that surgical weight loss improves the symptomatology. However, there are no studies to quantitatively assess the exact degree of functional disability caused by severe obesity and the degree of improvement of LBP that follows weight loss from bariatric surgery. Methods: 29 morbidly obese candidates for bariatric surgery with LBP, weight 132.5±27 (mean±SD) kg and BMI 47.2±8.8 kg/m² were examined for their functional status using psychometric instruments specifically designed to objectively assess the patients' complaints. The preoperative scores were measured by a) visual analogue scales (VAS1, VAS2, VAS3), b) Roland-Morris disability questionnaire, c) Oswestry LBP disability questionnaire, and d) Waddell disability index, and were compared with the scores obtained by the same instruments 2 years after vertical banded gastroplasty. Results: The postoperative weight (92.3±19 kg) and BMI (32.9±6.3 kg/m²) of the 29 patients were significantly reduced (P<0.001). The improved functional disability scores were statistically significant: a) VAS1 1.59±1.86 (mean±SD) vs 0.32±0.64, P<0.001; b) VAS2 5.5±1.97 vs 2.14±1.88, P<0.001; c) VAS3 0.77±1.11 vs 0.09±0.29, P=0.006, d) Roland-Morris 7.89±5.11 vs 1.89±2.13, P<0.001; e) Oswestry 21.22±15.63 vs 5.61±7.51, P<0.001; f) Waddell 2.81±1.37 vs 0.56±0.72, P<0.001. Conclusions: Surgical weight loss significantly improves the degree of functional disability of morbidly obese patients suffering from LBP.     

Obesity-associated disorders before and after weight reduction by vertical banded gastroplasty in morbidly vs super obese individuals

Background: The amount of excess weight which must be lost in order to cure or to improve disorders associated with obesity remains unknown. This study was designed to compare super obese and morbidly obese patients in terms of weight reduction following VBG and to investigate the effects of postoperative weight changes to preexisting co-morbidities. Methods: 125 patients underwent VBG. Group A consisted of 80 morbidly obese patients (64%) and group B consisted of 45 super obese patients (36%). Preoperative examination was planned to identify and determine the severity of any disorders associated with obesity, that the patients may have had. Following VBG, all patients were followed-up at regular time periods, for at least 2 and up to 4 years. The progress of preexisting co-morbidities was evaluated and carefully recorded. Results: Among the 80 patients of Group A, there were 240 total co-morbidities (3 per patient), and in group B there were 196 co-morbidities (4.35 per patient) preoperatively. Dyspnea during fatigue and arthritis were found at statistically higher incidence in the super obese category. At the end of the second postoperative year, greater weight loss in terms of number kilograms was seen in patients in group B, but these patients did not reach a BMI lower than 35, while patients in group A had mean BMI below 30. In group A, 66% of the co-morbidities completely resolved, 19% significantly diminished and 15% remain unchanged. In group B, the respective percentages were 53% , 27.5% and 19.5%. However, after weight reduction by VBG a significant number of co-morbidities remain in the super obese patients (92 or 2.044 per/patient), and this is believed to be due to the greater remaining excess weight. Conclusion: Reduction of body weight by VBG is associated with resolution or improvement of a significant number of the obesity-associated disorders. However, super obese patients remain obese after surgery, and this results in two-fold higher remaining morbidity.     

Histological Behavior of Hepatic Steatosis in Morbidly Obese Patients after Weight Loss Induced by Bariatric Surgery

Background: Hepatic steatosis has a high prevalence among morbidly obese patients. Its relation to steatohepatitis and cirrhosis has been extensively studied among these patients. The aim of this study was to evaluate the behavior of hepatic steatosis with weight loss 1 year after bariatric surgery. Methods: This study is a historical cohort that compared liver biopsies obtained from morbidly obese patients during the bariatric operation, with percutaneous biopsies taken from the same patient 1 year after surgery. The results were compared with weight loss, patients' profile (gender, age, body mass index (BMI) and waist/hip ratio), and with the presence of co-morbidities such as diabetes, hypertension, and dyslipidemia. Results: 90 patients who had liver biopsies taken at the operation and postoperative period for bariatric surgery were included. The prevalence of hepatic steatosis was 87.6%. The average percent of excess weight loss was 81.4%. On the second biopsy, 16 patients (17.8%) of the total had the same degree of steatosis, 25 (27.8%) improved their steatosis pattern and 49 (54.4%) had normal hepatic tissue. There was no statistical difference regarding age, BMI, waist/hip ratio, and co-morbidities (P>0.05), but there was a difference in gender (P=0.044). Conclusion: Significant improvement in the hepatic histology of steatosis was observed after weight loss induced by bariatric surgery in most patients. There was no patient with a worsening in the histology.     

Weight Loss Following Vertical Banded Gastroplasty: Intermediate Results of a Prospective Study

Background: Morbidly obese patients who undergo purely restrictive bariatric operations may fail to maintain satisfactory long-term results. In an attempt to achieve the best possible outcome after restrictive procedures, we have employed preoperative selection criteria and are following this selected patient group over time in order to evaluate longterm success. Materials and Methods: From June 1994 through August 2000, 166 morbidly obese patients underwent various bariatric procedures at our institution. Of these patients, 35 underwent vertical banded gastroplasty (VBG) based on selection criteria, including degree of obesity and dietary habits and eating behavior. All patients were seen at 1, 3, 6, 9, and 12 months postoperatively and yearly thereafter. Average follow-up time now is 4.1 years (29-75 mos.), and follow-up is 100%. A multivitamin and mineral supplement is administered to all patients for at least 6 months. Radiology examination is performed in all patients on the 4th postoperative day and at each yearly visit, in order to check for staple-line disruption and stomal stenosis. Results: Early postoperative morbidity was 5.7%. Late postoperative morbidity was 22.8%. A significant number of patients had some degree of stomal stenosis as shown by radiology examination, but to date there has been no need for surgical revision. There has been no early or late mortality.Weight loss results expressed as average percent excess weight loss (% EWL) were as follows: 61% (28-90) at 1 year, 61% (20-90) at 2 years, 57% (13-91) at 3 years, 56% (25-87) at 4 years and 37% (24-59) at 5 years following surgery. A significant number of patients with excellent weight loss had a high frequency of vomiting. Evaluation by BAROS showed that 25% of patients had an overall unsatisfactory outcome. Anemia and iron deficiency were found in 46% and 32% ofVBG patients respectively.Recurrence of preexisting comorbidities was significant if lost weight was regained. Conclusions: In spite of preoperative selection of patients for VBG, a significant percentage of patients had poor overall results in terms of weight loss, quality of life, and resolution of preexisting comorbidities. For these reasons and based on the long-term results published by others, VBG is no longer our preferred surgical option in morbidly obese patients.     

Psychiatric Diagnosis and Weight Loss following Gastric Surgery for Obesity

Background: The authors examined associations between lifetime Axis I and Axis II disorders and weight loss following gastric surgery for morbid obesity. Methods: 44 morbidly obese subjects who had undergone vertical banded gastroplasty (VBG) were systematically interviewed with the Diagnostic Interview Schedule (DIS) and were administered the Personality Diagnostic Questionnaire (PDQ). Subjects were followed-up 6 months post-VBG to determine weight loss. Results: The subjects had a mean ± SD age of 37.7 ± 10.6 years.Their baseline weight was 135.3 ± 28.0 kg and their baseline body mass index (BMI) was 50.0 ± 7.4. 34 (77%) were female. Results of linear regressions show a significant association between baseline BMI and weight loss at 6-month follow-up. After adjustment for baseline BMI, there was a non-significant trend toward increased weight loss in association with alcohol abuse/dependence. Similarly, among our analysis of 41 subjects who had received the PDQ, we found a non-significant trend toward increased weight loss in association with "any" PDQ diagnosis and with antisocial personality disorder/trait after adjusting for baseline BMI. Conclusion: The data suggest that Axis I and Axis II diagnoses were not predictive of weight loss following VBG during a 6-month follow-up.     

Long-Term Weight Loss after Bariatric Surgery in Patients Visited at Home Outside the Study Environment

Background: Bariatric surgery results in sustained weight loss in the majority of patients. The controlled setting of a trial, however, does not necessarily reflect the everyday routine practice. Therefore, to investigate the results of bariatric surgery in a more natural setting, patients were visited at home, outside a study and hospital environment. Methods: Patients who underwent a vertical banded gastroplasty or a gastric bypass between 1980 and 1997 were eligible. Body weight and height were measured. Patients filled out general and health status questionnaires (Nottingham Health Profile (NHP)). Results: Responses were obtained from 236/313 subjects (75%) with a mean ± SD age of 42.9 ± 10.2 years and a mean current body weight of 100.3 ± 20.7 kg. A maximum weight loss of 48.2 ± 18.4 kg or 70.8 ± 22.4% excess weight loss was obtained after 17 ± 15 months, of which 32.1 ± 22.6 kg or 45.2 ± 29.3%, respectively, was maintained at 8.2 ± 4.5 years after the intervention. Males and females did not differ in weight loss. The type of operation had no influence. Age >50 years and a BMI >50 kg/m² were not related to a poor outcome, but a time lapse of >5 years since the operation resulted in a less well sustained weight loss. The subjective health status improved considerably, but less so with a smaller weight loss and longer lapse of time since the operation. Especially in females, the NHP still deviated substantially from Dutch norm values. Conclusions: Surgically obtained weight loss is satisfactory in patients outside a strictly controlled study setting. Health benefits are substantial, but are adversely affected by weight gain and time elapsed since the operation.     

Gastric Myoelectrical Activity in Morbidly Obese Patients before and 3 Months after Gastric Restrictive Surgery

Background: Morbid obesity is often associated with gastrointestinal motor disorders. The aim of this study was to investigate gastric motility in morbid obesity, using electrogastrography (EGG) before and 3 months after gastric restrictive surgery. Methods: 40 morbidly obese subjects (age 40.6±10.3 years, BMI 46.4±5.7 kg/m²) were studied. VBG and Lap-Band? operations were performed in 19 and 21 patients respectively. The following EGG-parameters were determined, both during fasting (f) and postprandially (pp): dominant frequency (DF_f/pp), dominant power (DP_f/pp), dominant frequency and power instability coefficient (DFIC and DPIC respectively) and power ratio. Results: In the Lap-Band? group, DF_pp, DP_pp and DFIC_pp were significantly higher compared with the preprandial state, both preoperatively and 3 months postoperatively. After VBG, DF_f and DFIC_pp were significantly lower and DPIC_f significantly higher compared with the preoperative state. Furthermore, DF_pp and DP_pp were significantly higher than the preprandial values. However, in both types of operations, power ratio did not differ significantly between the preoperative and postoperative situation. Furthermore, no clear difference in EGG-parameters between both operations could be observed. Conclusion: After gastric restrictive surgery, no major changes in gastric myoelectrical activity occurred, suggesting that if clinical motility problems occur after bariatric surgery, they are not due to gastric myoelectrical dysfunction.     

Five-year results of laparoscopic vertical banded gastroplasty in the treatment of massive obesity

Background: Laparoscopic surgery appears to offer rapid recovery and low postoperative morbidity.The aim of the present study was to assess the outcome of laparoscopic vertical banded gastroplasty (LVBG) in 154 obese patients with a follow-up of 12-60 months. Patients and Methods: 154 massively obese patients (132 female) with a mean ±SEM body mass index (BMI) of 43.4±0.6 kg/m² were followed prospectively for an average of 31.7±1.4 months. LVBG was performed using 5 trocars placed in a standard fashion for laparoscopic upper gastrointestinal surgery. A 4-row stapler was used for the vertical staple-line and a stretched polytetrafluoroethylene (Gore-tex^?) band was used to reinforce the outlet. After the first 67 cases, the procedure was altered so that a 5-cm length was marked on the band. Results: Conversion to open surgery was performed in 33 cases. All patients lost weight. At 60 months follow-up, the postoperative weight was similar in the open and laparoscopic group.The subjects where 5 cm length was marked on the band had a significantly better weight loss at 36 months (30.4 ±1.2). Both early (<1 month postoperative) and late (>1 month postoperative) complications were more common in the group converted to open surgery. Postoperative stay was shorter in the laparoscopic group. Conclusions: LVBG can be performed safely and results in shorter postoperative stay than openVBG. With adherence to surgical technique (5-cm band circumference), weight-loss is maintained at an adequate level. Complications after LVBG do not exceed open VBG.     

Technical Modification of Laparoscopic Vertical Banded Gastroplasty

Background: Technical improvements of laparoscopic bariatric procedures are important to minimize operative time and increase safety and simplicity. Methods: A modification is described of the "classic" Mason - MacLean vertical banded gastroplasty (VBG), performed by laparoscopy, with wedge resection of the gastric fundus, thus avoiding the time-consuming and technically difficult gastro-gastrostomy window. Results: The technique used was simple and safe, and required less operative time than the "classic" method, without serious intra- or postoperative complications. Weight loss in 18 patients who underwent the modified laparoscopic VBG and were followed-up for 1 year was equal to that achieved in patients who underwent openVBG at our Institution. Gastro-gastric fistula was not observed in upper GI barium studies performed 12 months postoperatively. Conclusion: The modified technique is preferable when lap-VBG is indicated for surgical treatment of morbidly obese patients.     

Psychopathological Status and Interpersonal Functioning Following Weight Loss in Morbidly Obese Patients Undergoing Bariatric Surgery

Background: We questioned whether differences in psychopathological status and interpersonal relations exist in a group of morbidly obese patients 18 months after bariatric surgery,as related to extent of weight loss. Methods: The study group consisted of 100 morbidly obese patients (85 female, 15 male) who had undergone surgical treatment (vertical banded gastroplasty) for weight reduction. Each patient completed the Lancashire Quality of Life Profile - European version, the Eating Disorder Inventory,the Symptom Check List-90-Revised, and the Millon Clinical Multiaxial Inventory-II. The sample was divided into 2 groups according to the percentage of excess weight loss 18 months after surgery: a greater weight loss group (weight loss >30%) and a lesser weight loss group (weight loss <30%). Results: Significant differences were found between the 2 groups in percentage of weight loss (P<0.0001), negative self-esteem (P<0.001), drive for thinness (P<0.001), body dissatisfaction (P<0.001), global EDI (P<0.002), anxiety (P<0.003), GSI (P<0.002), avoidant (P<0.001), borderline (P<0.0001), and passive-aggressive (P<0.002). Conclusion: Greater weight loss strongly correlates with improved quality of life, less disturbed eating behavior, and lower psychopathology. These results justify the clinical use of surgical procedures and demonstrate that weight loss has powerful psychological and psychosocial implications.     

Impartial long-term review of vertical banded gastroplasty in a low volume community hospital practice

Background: There is some concern whether bariatric surgery can be done well at low volumes or in a community hospital setting. This paper reports an impartial assessment of 25 vertical banded gastroplasties (VBG) over 13 years in a 228-bed non-teaching community hospital. Methods: Charts were reviewed and patients interviewed by an independent investigator. Complications, weight loss, satisfaction and quality of life were assessed. Results:There were no fatalities, no splenic tears, no stomal stenosis and no symptomatic gastroesophageal reflux. Two reoperations and five incisional hernias were noted. Hypertension was eliminated in 57% and dyspnea in 55%. BMI fell from 44.3 to 34.9 kg/m2 after 6.2 years. BMI decreased more than 10 kg/m2 (10-30) for 15 patients and less than 10 kg/m2 for 10 patients (4-10 for 7, 0 for 1 and a gain for 2). 56% of patients were fully satisfied with the results. Quality of life indicated excellent physical function, physical role and lack of body pain, good general health, social function, emotional role and mental health, but lower vitality.100% felt better than a year ago. Conclusion: Results from a low-volume community hospital general surgical practice are similar to those from specialized series. Obesity is so common, its non-surgical treatment so ineffective and the VBG so well established, that excluding this intervention from community hospitals is untenable.     

Efficacy and Safety of Patient-Controlled Analgesia for Morbidly Obese Patients Following Gastric Bypass Surgery

Background: Adequate postoperative pain control is important to reduce potential cardiopulmonary complications. It is often difficult to determine dosages of narcotics for morbidly obese patients following Rouxen-Y gastric bypass (RYGBP) due to respiratory depression. Individualization of analgesic therapy, patient-controlled analgesia (PCA), can provide optimal dosage for pain control and minimize the side-effects. Method: 25 morbidly obese patients who received PCA with morphine sulfate following RYGBP. PCA settings we re as follows: morphine, 20 μg/kg of ideal body weight, 10-minute lock out interval and 80% of a calculated amount for a 4-hour limit.We measured arterial blood gas, heart rate, mean arterial pressure, arterial oxygen saturation, respiratory rate, opioid amount, patient satisfaction, visual analog pain scale (VAS), and the incidence of nausea, vomiting, pruritus and sedation. Results: Average morphine usage was 44.2±28.7 mg during the day of surgery (DOS); 49.1±27.4 mg during POD (postoperative day) #1; and 36.6±22.8 mg during POD#2 (p < 0.01). 24 patients were satisfied with their pain control on POD#1. VAS was 5.4±2.1 on the day of surgery, but remained below 4 thereafter. Arterial oxygen saturation and vital signs were maintained without significant changes. 5 patients experienced mild sedation on the day of surgery and 3 patients experienced mild sedation on POD#1. 1 patient experienced nausea and vomiting and 4 patients had pruritus; however, none required treatment. Conclusion: PCA is safe and effective for morbidly obese patients following RYGBP.     

A Correlation Method for Weight Loss after Gastroplasty

Background: Prevalence of morbid obesity is increasing in western countries. As a consequence, bariatric surgery has intensively developed in the last decades. Someone facing the need for comparison between gastric restrictive procedures could find it useful to have a general expression for weight loss after surgery. Methods: A first approach of this issue can be made, taking into account two simple hypotheses: linear dependencies of weight variation versus sum of energy transfer, and of loss of energy versus weight. With the additional assumption of a constant energy income (the goal of surgery), one can obtain for the weight loss ΔP=P₀-P=(P₀-B)(1-e^-βt), where P and P₀ are the weight at time t and t₀, B and β being adjustable constants. Results: A preliminary study has shown us that most of our weight loss data could be fitted using such an expression. The model was successfully tested on gastric banding and calibrated vertical banded gastroplasty data, but with greater emphasis on laparoscopic vertical banded gastroplasty. Conclusion: We introduce a simple, exponential growth-like function that can be used for the fit of weight loss data of patients who underwent bariatric surgery in our surgical unit. Such a function could also be of practical interest for the survey of weight loss.     

Comparison of Bariatric and Non-Bariatric Elective Operations in Morbidly Obese Patients on the Basis of Wound Infection

Background: Wound infection rates after various types of bariatric operations have been well described. The question of whether bariatric surgery increases wound infection rate compared with similar elective surgical procedures in obese patients has not been clearly answered. The purpose of this study was to investigate wound status of morbidly obese patients after elective general surgery. Methods: A prospective evaluation was conducted of 141 morbidly obese patients undergoing bariatric (n=60) and non-bariatric elective general surgery operation of similar invasiveness (n=81) with the ASEPSIS wound surveillance method. Results: Median age of patients undergoing non-bariatric elective surgery (51, 32-68) was significantly higher than patients exposed to bariatric surgery (39, 24-57). Patients undergoing bariatric surgery had higher BMIs (44.0, 35-52.5) compared to the others (38.4, 35-43). All patients enrolled in the study were followed for a 21-day period. At the 7th postoperative day, 9 patients in the bariatric surgery group developed infection (15%), whereas 13 patients (16%) in the non-bariatric surgery group suffered wound infection. Wound infection was still present in 2 patients (3.4%) in the bariatric surgery group and 3 patients (3.7%) in the non-bariatric surgery group at the 21st day. Risk factors for wound infection included history of coronary artery diseases, diabetes, chronic respiratory illness and malignant disease. Conclusion: Bariatric surgery does not cause an additional risk of postoperative wound infection in morbidly obese patients, compared to elective general surgical operations of the same invasiveness.     

Gallstone Formation after Weight Loss following Gastric Banding in Morbidly Obese Dutch Patients

Background: Obesity is a risk factor for the development of gallstones. Rapid weight loss may be an even stronger risk factor. We retrospectively assessed the prevalence and risk factors of gallstone formation after adjustable gastric banding (AGB) in a Dutch population. Methods: All patients who underwent AGB between Jan 1992 and Dec 2000 for morbid obesity were invited to take part in this study. Transabdominal ultrasonography of the gallbladder was performed in those patients without a prior history of cholecystectomy (Group A). Additionally, 45 morbidly obese patients underwent ultrasonography of the gallbladder before weight reduction surgery (Group B). Results: 120 patients were enrolled in the study (Group A). Prior history of cholecystectomy was present in 21 patients: 16 before and 5 after AGB. Ultrasonography was performed in 98 patients: gallstones were present in 26 (26.5%). On multivariate analysis, neither preoperative weight, nor maximum weight loss, nor the interval between operation and the postoperative ultrasonography were determinants of the risk for developing gallstone disease. Prevalence of gallstones was significantly lower in the morbidly obese patients who had not yet undergone weight reduction surgery (Group B). Conclusions: Rapid weight loss induced by AGB, is an important risk factor for the development of gallstones. No additional determinants were found. Every morbidly obese patient undergoing bariatric surgery must be considered at risk for developing gallstone disease.     

Personality Profiles of the Morbidly Obese after Vertical Banded Gastroplasty

Background: The authors attempted to determine if mental status could predict personality profiles, 18 months after surgery in morbidly obese patients. Methods: Personality characteristics of 100 morbidly obese patients (85 female, 15 male) were analyzed after bariatric surgery (vertical banded gastroplasty). Patients were given the Millon Clinical Multiaxial Inventory-II (MCMI-II). Data were compared with a Spanish clinical population to validate the test in our country. Results: Significant differences were found in Schizoid scale (P<0.0001), Paranoid scale (P<0.001), Histrionic scale (P<0.0001), Compulsive scale (P<0.0001), and Delusional disorder scale (P<0.0001) between the two groups. When psychiatric comorbidity appeared, there were higher values on these scales. Conclusions: Morbidly obese patients undergoing bariatric surgery show traits and personality disturbances, and the mental state impairs the personality structure.     

Hand-assisted laparoscopic vertical banded gastroplasty: technique and analysis of the first 140 cases

Background:The use of laparoscopic surgery to perform bariatric operations offers advantages to morbidly obese patients. Between January 1999 and June 2001, 140 patients underwent hand-assisted laparoscopic VBG using the Handport^™ System. Methods: In the 110 females (78.6 %) and 30 males (21.4 %), mean age was 38 years (range 19-65), mean body weight 115.8 kg (range 89-200), and mean BMI 41.8. Severe obesity was present in 41%, morbid obesity in 41% and super obesity in 9% of the patients. Comorbid conditions included hyperlipidemia in 70% of patients, arthritis in 44%, hypertension in 38%, COPD in 18%, GERD in 12%, impaired glucose tolerance and diabetes in 10%, sleep-apnea in 5% and coronary heart disease in 1%. Results: There was no operative mortality. Mean excess weight loss was 60.7% at 12 months and 63% at 18 months. Mean BMI was 30.8 at 12 months and 30.4 at 18 months. A decrease in BMI of 11 kg/m² was reached at 12 months. According to the Reinhold Classification (residual excess weight <50%), good to excellent results were achieved in 75.7% at 1 year and in 77.7% at 18 months. Early postoperative complications were 4 wound infections, 3 atelectasis or pneumonia, 1 deep vein thrombosis, 1 subphrenic abscess and 1 wound hematoma. Late postoperative complications were 2 incisional hernias, 2 esophagitis, 1 symptomatic gallstones, 1 staple-line fistula, 9 protracted vomiting and 6 band-related problems. Conclusions: The short-term results compare favorably with the literature on open VBG. Because of the reduction of perioperative risks with the laparoscopic approach, bariatric surgery should be performed laparoscopically if the expertise is available.     

Gastric Cancer Occurring After Vertical Banded Gastroplasty

A case of gastric cancer after vertical banded gastroplasty (VBG) is presented. A 44-year-old man presented with vomiting and weight loss 6 years after VBG. Endoscopy revealed a poorly differentiated gastric adenocarcinoma. The patient underwent a Whipple pancreaticoduodenectomy and received chemotherapy. He expired 6 months later. From our case and review of the literature, development of gastric cancer after VBG is very rare. The authors suggest that patients undergoing VBG be monitored by endoscopy after the operation.     

Laparoscopic Vertical Banded Gastroplasty: Early Experience

Background: The tremendous development of laparoscopic surgery in the last decade is being applied to bariatric surgery. Laparoscopic vertical banded gastroplasty (LVBG) is technically feasible by laparoscopy. Methods: From August 1998 to August 1999, 13 patients underwent LVBG. The technical difficulties are discussed. Results: Operating time ranged from 105 to 420 minutes. 11 patients have lost 45-55% of their original weight. Inserting an esophageal bougie no. 11 from the beginning of the operation and using the laparoscopic set-up described, made the procedure shorter, safer and easier for patients and surgeon. Conclusion: LVBG is technically feasible for the laparoscopic bariatric surgeon who is experienced in the handling and control of laparoscopic instruments and hand-eye coordination. The early results are satisfactory. Preoperative counseling is an integral step for the operation.     

Plasma Antioxidant Capacity in Morbidly Obese Patients Before and After Weight Loss

Background: Oxidative stress may play a critical role in the pathogenesis and development of obesity-associated co-morbidities. Reactive oxygen and nitrogen species are produced as a consequence of normal aerobic metabolism and removed and/or inactivated in vivo by both endogenous (uric acid, bilirubin, thiols) and diet-derived (exogenous) antioxidants. The purpose of this study is to measure the total plasma antioxidant capacity (TAC), as well as the corrected TAC (cTAC, an index of exogenous provided antioxidants) in morbidly obese patients before and after surgical weight reduction. Methods: 16 morbidly obese (5 male and 11 female) candidates for surgical intervention, median age 34 (range 22-56) years, median weight 128 (range 96-186) kg, median excess weight 62 (range 28-115) kg and median BMI 44.4 (range 33.7-60.1) kg/m² were evaluated before and 6 months after implantation of an intragastric balloon. 15 healthy blood donors (4 male and 11 female) on a normal diet, median age 35 (range 21-52) years, median weight 64.3 (range 46-78) kg and median BMI 24.2 (range 23.7-25.2) kg/m² were also evaluated. Blood samples for routine clinical chemistry, TAC and cTAC determination were drawn, and weight and BMI calculation were performed once in the control group, and in the morbidly obese patients (MO) before and 6 months after the balloon implantation. Results: 6 months after balloon placement, weight and BMI of the MO patients were statistically significantly reduced from the preoperative values (P<0.001). Plasma TAC and cTAC values in the MO group were significantly lower preoperatively, compared to the control group (P<0.05 and P<0.001 respectively). cTAC values in the MO patients increased significantly following weight loss (P<0.001) and were restored to normal. However, the postoperative TAC values in the MO group did not change significantly and remained lower than in the normal controls. A significant decrease (P<0.001) in uric acid values was also noticed in the MO group after weight loss. Conclusion: Plasma TAC and cTAC values are impaired in morbidly obese patients. Weight loss from an intragastric balloon is associated with significant increase in plasma cTAC values. Plasma TAC values, after the weight loss remain unchanged, possibly due to a decrease in uric acid, an important endogenous antioxidant.