Resolution of Diabetes Following Vertical Gastroplasty in Morbidly Obese Patients

Case reports are presented on three patients treated for morbid obesity by vertical gastroplasty. Prior to surgery the patients had diabetes which required insulin, up to 200 units per day, or oral hypoglycaemics for its control. Six months after surgery the diabetes had been resolved in all three patients, and they were no longer dependent on medication. Subjective reports from the patients suggests that their quality of life improved significantly.     

Laparoscopic Cholecystectomy in Obese and Nonobese Patients

Background: From November 1997 to November 1998, 145 cases of laparoscopic cholecystectomy (LC) have been attempted at the District General Hospital of Corfu. Methods: 23 (15.8%) were obese (Group I, BMI >30) and 122 (84.2%) were nonobese patients (Group II, BMI ≤30). One-fifth of these patients suffered from acute cholecystitis. Results: Operative time averaged 95 minutes in Group 1 and 78 minutes in Group II. There were no deaths. There were no significant differences between the obese and nonobese groups in conversion to open procedure (Group1: 0%, Group II: 2.4%), intraoperative and postoperative complications (Group I: 4.3%, Group II: 4.0%), operating time, and length of postoperative hospitalization. Conclusion: LC was a safe and effective treatment for obese patients with symptomatic cholelithiasis.     

Myocardial Mass in Morbidly Obese Patients and Changes with Weight Reduction

Cardiac weight was determined at autopsy in 27 morbidly obese, but otherwise healthy men (mean weight 168 kg) and women (mean weight 138 kg) who died suddenly, prior to, or shortly after gastric restriction operations for relief of obesity. They had lost no weight. Post-mortem examination revealed no cardiac or other pathology explaining the cause of death. Cardiac weight was also measured in 25 men and women of equivalent baseline weight and body mass index who, after operation, subsisted on a hypocaloric diet for 3-4 months after operation, but then died suddenly. Mean weight losses of this latter group were 45.8 kg in men and 32.9 kg in women. No cardiac abnormalities and no organic causes of death were found at autopsy. Decreases in heart weight were calculated. The baseline measurements demonstrated that cardiac weight in the healthy obese rose with increasingly severe obesity in both sexes, but the increase tended to lessen with more extreme obesity. The generally quoted figures of cardiac weight as a fraction of body weight are 0.043 and 0.040% for men and women, respectively. In the group of morbidly obese men, cardiac weight was 0.035% of body weight or 16% lower than predicted. In morbidly obese women, cardiac weight was 0.030% of body weight or 25% lower than predicted. In men, a 28% body weight reduction due to dietary restriction resulted in a proportionately similar 20% decrease in cardiac weight. In contrast, in women after a 27% loss of body weight, cardiac weight decreased only 5%. Severe dietary restriction with a drastic body weight loss did not result in a disproportionate decrease of cardiac weight in either sex, when final body weight had remained above or in the normal range.     

Changes in Body Image Disturbance in Morbidly Obese Patients 1 Year after Laparoscopic Adjustable Gastric Banding

Background The effectiveness of post-surgical weight loss in improving body image disturbance (BID) in morbidly obese patients is still unclear. Providing multidimensional measures of BID and controlling for the effect of co-morbid eating psychopathology may help to clarify this issue. This preliminary study explores whether 1) BID improves 1 year after laparoscopic adjustable gastric banding (LAGB), and whether 2) such improvement is related to post-surgical BMI and/or eating disorder reduction. BID was multidimensionally assessed by means of the Body Uneasiness Test(BUT). Methods 35 obese subjects (mean BMI 45.5) were evaluated prior to and 1 year after LAGB using the BUT, and a standardized interview and questionnaire to assess eating psychopathology. BID and eating habit changes during follow-up were also investigated. Postoperative BUT values were entered as outcome measures (dependent variables) in a series of stepwise multiple regression analyses; BMI and binge eating reduction, baseline BUT scores, gender, age, and age of onset of obesity were tested as independent variables. Results Some aspects of BID (body image overconcern and related avoidance behaviors, compulsive self-monitoring, and overall severity of BID) improved following LAGB, while others (weight phobia, depersonalization, and uneasiness toward body parts) did not. The post-surgical lower levels of the former were predicted by the overall decrease in binge eating symptoms, irrespective of BMI reduction, age, gender, and age of onset of obesity. Conclusions LAGB may ameliorate some BID aspects in morbidly obese patients, and an improvement in eating behaviors may contribute to this effect.     

Technical Aspects of Laparoscopic Sleeve Gastrectomy in 25 Morbidly Obese Patients

Background Laparoscopic sleeve gastrectomy (LSG) has recently come to be performed as a sole bariatric operation. The postoperative morbidity and mortality are cause for concern, and possibly are related to non-standardized surgical technique. Methods The following is the surgical LSG technique used in 25 morbidly obese patients. Five trocars are used. Division of the vascular supply of the greater gastric curvature is begun at 6–7 cm proximal to the pylorus, proceeding to the angle of His. A 50-Fr calibrating bougie is positioned against the lesser curvature. The LSG is created using a linear staplercutter device with one 4.1-mm green load for the antrum, followed by five to seven sequential 3.5-mm blue loads for the remaining gastric corpus and fundus. The staple-line is inverted by placing a seroserosal continuous absorbable suture over the bougie from the angle of His .The resected stomach is removed through the 12-mm trocar, and a Jackson-Pratt drain is left along the suture-line. Results The mean operative time was 120 minutes, and length of hospital stay was 4 ± 2 days.There were no conversions to open procedures. There were no postoperative complications (no hemorrhage from the staple-line, no anastomotic leakage, no stricture) and no mortality. In 1 patient, cholecystectomy was also done, and in 4, a gastric band was removed. During a median follow-up of 4 months, BMI decreased from 43 ± 5 kg/m² to 34 ± 6 kg/m², and the % excess BMI loss was 49 ± 25%. Conclusions The proposed surgical technique appears to be a safe and effective procedure for morbid obesity.     

Alterations in Thyroid Hormones and Thyrotropin (TSH) in Morbidly Obese Patients before and after Vertical Gastroplasty

Background: Published results of studies of thyroid function in obesity and after weight loss have differed. Methods: The circulating concentrations of thyroid hormones and TSH were studied in 30 consecutive, euthyroid morbidly obese patients before and after weight loss from vertical gastroplasty, with the aim to determine the relation between body weight loss and pituitarythyroid axis function. Serum TSH, free T3 (FT3) and free T4 (FT4) were measured before operation and repeated 6 and 18 months postoperatively. Results: A significant increase, but within normal levels, in FT3 value at 6 and, mainly, at 18 months after gastroplasty was observed (p = 0.002). The FT4 value was slightly increased at the same time and serum TSH was found to be significantly decreased (p = 0.03 and p = 0.01 respectively). The relative increase in FT4 was negatively correlated with excess body weight and Body Mass Index reduction. This correlation was only moderate with values ranging from r = 0.34 to r = 0.47. Conclusions: Although there were statistically significant differences in thyroid function tests before and after loss of weight, these were not biologically significant. The hypophyseal/thyroid axis remains always active and contributes to body weight homeostasis and its regulation.     

Bariatric Surgery in Morbidly Obese Patients in Wheelchairs

Two morbidly obese patients are presented. The first patient is a 38-year-old superobese female with BMI 56.2 in a wheelchair secondary to multiple sclerosis. The second patient is a 49-year-old female with BMI 47.7 confined to a wheelchair secondary to spinal cord transection due to a motor vehicle accident. Both patients underwent an open duodenal switch procedure, which provided significant weight loss and improved quality of life primarily for mobility with a wheelchair, as well as controlling comorbidities.     

Randomized Comparison of Isoflurane and Sevoflurane for Laparoscopic Gastric Banding in Morbidly Obese Patients

Study Objective: To compare the efficacy and recovery profile of sevoflurane and isoflurane as the main anesthetics for morbidly obese patients.

Design: Randomized, blinded study.

Setting: Inpatients.

Patients: 30 ASA physical status II and III obese patients [body mass index (BMI) > 35 kg/m²] undergoing laparoscopic gastric banding for morbid obesity.

Interventions: After standard intravenous induction of general anesthesia and tracheal intubation, anesthesia was maintained with either sevoflurane or isoflurane as the main anesthetics. The end-tidal concentrations of the volatile drugs were adjusted to maintain systolic arterial blood pressure within ±20% from baseline values. When the surgeon started the skin suture, the end-tidal concentration of the inhalational drug was reduced to 0.5 minimum alveolar concentration in both groups. At the last skin suture, the inhalational drug was discontinued and the vaporizator was removed to allow blinded evaluation of the emergence times.

Measurements and Main Results: No differences in anesthetic exposure, hemodynamic parameters, incidence of untoward events, or postoperative pain relief were reported between the two groups. Extubation, emergence, and response times were shorter after sevoflurane [6 min (3–15 min), 8 min (5–18 min), and 12 (6–25 min)] than isoflurane [10 min (6–26 min), 14 min (6–21 min), and 21 min (14–41 min)] (p = 0.001, p = 0.03, and p = 0.0005, respectively). The median time for postanesthesia care unit discharge was 15 minutes (25th—75th percentiles: 10–18 min) after sevoflurane and 27 minutes (25th—75th percentiles: 20–30 min) after isoflurane (p = 0.0005).

Conclusions: Sevoflurane provides a safe and effective intraoperative control of cardiovascular homeostasis in morbidly obese patients undergoing laparoscopic gastric banding, with the advantage of a faster recovery and earlier discharge from the postanesthesia care unit than isoflurane.     

High Prevalence of Asymptomatic Esophageal Motility Disorders among Morbidly Obese Patients

Background: Morbid obesity is becoming more prevalent in the industrialized world. Few data exist regarding the resting lower esophageal sphincter pressure (LESP) and esophageal motility in relationship to body mass index (BMI). Methods: During a 3-year period, 111 of 152 morbidly obese patients seeking bariatric surgery completed esophageal manometric testing and questionnaire regarding esophageal symptoms. Manometric parameters included wave amplitude and duration of esophageal contractions, percentage of peristaltic function, and resting LESP. Questionnaire data included age, sex, medications, prior medical conditions, and esophageal symptoms. Results: 88 (79%) of the patients were female; 23 (21%) were male. The mean age was 39.8 years (± 9.9), the mean BMI was 50.7 kg/m2 (± 9.4). There was a lack of correlation between BMI and LESP (r = 0.04). Abnormal manometric findings were observed in 68/111 (61%) patients: 28 (25%) had only hypotensive lower esophageal sphincter (LESP < 10 mm Hg); 16 (14%) had nutcracker esophagus (amplitude >180 mm Hg), 15 (14%) had nonspecific esophageal motility disorders, 8 (7%) had diffuse esophageal spasm (DES), and 1 (1%) had achalasia. Patients with DES had a significantly higher BMI than those with other motility disorders (P < 0.05). Dysphagia was reported in 7 (6%) patients and chest pain in 1 patient. Heartburn and/or regurgitation (gastroesophageal reflux disease, GERD) was noted in 35 patients (32%), of whom 18 (51%) had a hypotensive resting LES. 40 of 68 patients (59%) with abnormal motility tracings did not report any esophageal symptoms. Conclusion: Morbid obesity per se does not imply an abnormality of LESP. In addition, a majority of morbidly obese patients who were considering bariatric surgery had no esophageal symptoms but were found to have abnormal esophageal manometric patterns. These findings add support to the suggestion that morbidly obese patients may have abnormal visceral sensation.     

Robotic-Assisted Laparoscopic Hysterectomy: Outcomes in Obese and Morbidly Obese Patients

Objective:

To describe patient characteristics and perioperative outcomes among women undergoing robotic-assisted laparoscopic hysterectomy and to evaluate the characteristics of nonobese, obese, and morbidly obese patients.

Methods:

A retrospective review was conducted of 442 cases of women who underwent robotic-assisted laparoscopic hysterectomy for benign and malignant conditions over a 4-y period at an academic and community teaching hospital. Patient demographics, surgical indications, operative outcomes, and complications were evaluated for patients with a body mass index (BMI) <30 kg/m², 30 kg/m² to 39.9 kg/m², and ≥40 kg/m².

Results:

Of the 442 patients, 257 (58%) were obese or morbidly obese, with a BMI of ≥30 kg/m². Overall, the median estimated blood loss was 100 mL (range, 10 to 800), the operative time was 135 min (range, 40 to 436), and the length of stay was 1 d (range, 0 to 22). These did not differ significantly by BMI group. Overall, 11.9% of patients experienced complications (7.9% minor, 4.1% major), and this did not differ significantly across BMI groups.

Conclusion:

Robotic hysterectomy can be performed safely in obese and morbidly obese patients, with surgical outcomes and complications similar to those in nonobese patients.     

Diagnostic Value of Ultrasonographic Examination for Nonalcoholic Steatohepatitis in Morbidly Obese Patients Undergoing Laparoscopic Bariatric Surgery

Background There are few data relating to the role of fatty score (FS) and modified fatty score (MFS) in ultrasonographic (US) examination on the diagnosis of nonalcoholic steatohepatitis (NASH) in patients undergoing bariatric surgery. Methods We investigated consecutive patients undergoing laparoscopic bariatric surgery with biopsy-proven nonalcoholic fatty liver disease. Patients with other liver diseases and significant alcohol consumption were excluded. Clinico-demographic and anthropometric data were collected before surgery. Each biopsy specimen was assessed by the same pathologist. Liver US examinations were performed by an independent and experienced sonographer before surgery. FS and MFS, determined by the US scoring system based on degrees of parenchymal echogenicity, far gain attenuation, gallbladder wall blurring, portal vein wall blurring and hepatic vein blurring, were used to assess the severity of fatty liver. US findings were correlated with histologic results. Results Totally 101 patients were enrolled. The mean BMI of the patients was 44.6 ± 5.4 kg/m². 29 patients (29%) were categorized with simple steatosis and 72 (71%) with NASH. FS and MFS were significantly correlated with the histological steatosis, fibrosis and the presence of NASH (P < 0.001). A receiver operating characteristic curve identified the MFS of 2 as the best cut-off point for the prediction of NASH, yielding measures of sensitivity, specificity, positive predictive value, and accuracy for 72%, 86%, 93% and 76%, respectively. The positive likelihood ratio of 5.24 for MFS approximately doubled the post-test probability of NASH from 30% to 70%. Conclusion FS and MFS on US examination exhibit acceptable sensitivity and high specificity for the detection of the presence of NASH in morbidly obese patients and may aid in the selection of patients for closer follow-up or liver biopsy.     

Laparoscopic Solution for Early Gastric Cancer in a Morbidly Obese Patient

During preoperative work-up for laparoscopic gastricbypass in a morbidly obese female, gastroscopy visualizedtwo small ulcers in the antrum. Biopsies diagnosedadenocarcinoma of the diffuse type. Stagingwas performed, and endoscopic ultrasonographyshowed early gastric cancer. A laparoscopic neartotalgastrectomy with D1 resection and perigastriclymph node dissection and full omentectomy in combinationwith a gastric bypass, was peformed. Thisapproach respects the oncologic and bariatric principlesand gives a combined solution for the patient.     

Prevalence and Severity of Sleep Apnea in a Group of Morbidly Obese Patients

Background Obesity is the most important risk factor for obstructive sleep apnea. It is estimated that 70% of sleep apnea patients are obese. In the morbidly obese, the prevalence may reach 80% in men and 50% in women. The aim of this study was to determine the prevalence and severity of sleep apnea in a group of morbidly obese patients, leading to bariatric surgery. Methods In a cross-sectional study developed in Bahia, northeastern Brazil. 108 patients (78 women and 30 men) from the Obesity Treatment and Surgery Center - “Núcleo de Tratamento e Cirurgia da Obesidade” underwent standard polysomnography. Patients with an apnea-hypopnea index (AHI) ≥ 5 events/hour were considered apneic. Results Mean ± SD for age and BMI were 37.1 ± 10.2 years and 45.2 ± 5.4 kg/m2, respectively. The calculated AHI ranged widely from 2.5 to 128.9 events/hour. Sleep apnea was detected in 93.6% of the sample, wherein 35.2% had mild, 30.6% moderate and 27.8% severe apnea. Oxyhemoglobin desaturation was directly related to the AHI and was more severe in men. Conclusion There was a high frequency of sleep apnea in this group of morbidly obese patients, for whom it was very important to request polysomnography, thus enabling therapeutic management and prognostication.     

Plasma Protein Carbonyl and Thiol Stress Before and After Laparoscopic Gastric Banding in Morbidly Obese Patients

Background The aim of this study is to examine the relationship between oxidative plasma protein and thiol stress and weight loss after laparoscopic adjustable gastric banding (LAGB). Methods Plasma protein carbonyl (PCO) concentration as a marker of protein oxidation, plasma thiol (PSH) and erythrocyte glutathione concentration (GSH, major intracellular thiol), as an antioxidant and metabolic markers, such as Homeostatic Model Assessment – Insulin resistance (HOMA-IR), BMI and plasma lipids were determined in morbidly obese patients (n 22, mean age 34.7 ± 11 years, BMI 48.4 ± 6.4 kg/m²) at baseline and 1 and 6 months after operation. Baseline levels in patients were also compared with the levels in agematched controls (n 20, BMI 21.3 ± 1.8 kg/m²). Plasma PCO and thiols and erythrocyte GSH concentrations were determined spectrophotometrically. Results Plasma PCO were significantly higher and plasma and erythrocyte thiol concentrations were significantly lower in morbidly obese patients than in controls (for each comparison, P < 0.01). BMI, plasma triglycerides and HOMA-IR were positively correlated with plasma PCO and negatively correlated with plasma P-SH and erythrocyte GSH (for each comparison, P < 0.01). Plasma HDL-cholesterol levels were positively correlated with plasma erythrocyte GSH (r = 0.405, P < 0.01) and negative correlated with plasma PCO (r = −0.273, P < 0.01). One and 6 months after the LAGB operation, total weight loss was 13.2 ± 6.3 and 35.5 ± 7.5 kg, respectively. Plasma PCO concentrations were decreased and P-SH and erythrocyte GSH concentrations were elevated following weight loss (for each, P < 0.01). Only plasma P-SH levels were restored to the control levels 6 months after LAGB. Conclusions Obesity and insulin resistance appear to be associated with plasma protein oxidation and thiol concentrations. Protein and thiol oxidative stress was improved by weight loss after LAGB in the short-term.     

Video-Assisted Versus Conventional Tracheal Intubation in Morbidly Obese Patients

Background  We compared tracheal intubation characteristics and arterial oxygenation quality during airway management of morbidly obese patients whose trachea was intubated under video assistance with the LMA CTrach™ (SEBAC, Pantin, France) or the Airtraq™ laryngoscope (VYGON, écouen, France) with that of the conventional Macintosh laryngoscope. Methods  After standardized induction of anesthesia, 318 morbidly obese patients scheduled for elective morbid obesity surgery received tracheal intubation with the LMA CTrach™, the Airtraq™ laryngoscope, or the conventional Macintosh laryngoscope. Duration of apnea, time to tracheal intubation, and oxygenation quality during airway management were compared between the LMA CTrach™ and the laryngoscope groups. Results  Patients’ characteristics were similar in the three groups. The success rate for tracheal intubation was 100% with the LMA CTrach™ and the Airtraq™ laryngoscope. One patient of the Macintosh laryngoscope group received LMA CTrach™ intubation because of early arterial oxygen desaturation associated with unstable facemask ventilation. The duration of apnea was shorter with the LMA CTrach™ than that of the Airtraq™ laryngoscope and the Macintosh laryngoscope. The duration tracheal intubation was shorter with the Airtraq™ laryngoscope than with the Macintosh laryngoscopes and the LMA CTrach™. During airway management, arterial oxygenation was of better quality with the LMA CTrach™ and the Airtraq™ laryngoscope than that of the Macintosh laryngoscope. Conclusion  Because LMA CTrach™ promoted short apnea time and the Airtraq™ laryngoscope allowed early definitive airway, both video-assisted tracheal intubation devices prevented most serious arterial oxygenation desaturation evidenced during tracheal intubation of morbidly obese patients with the conventional Macintosh laryngoscope. Support was provided solely from department sources. LMA and PRODOL Companies promoted material support for the airways.     

Significant Changes in the Lipid-Lipoprotein Status of Premenopausal Morbidly Obese Females following Gastric Bypass Surgery

The morbidly obese premenopausal female may be more dyslipoproteinemic and at greater risk for developing coronary heart disease than her lean or less seriously obese counterparts. The purpose of the present study was to examine the effects of weight loss with Roux-en-Y gastric bypass surgery on the lipid-lipoprotein status of morbidly obese, premenopausal females. Anthropometrics and blood samples for lipid-lipoprotein analyses were obtained before surgery and 6 - 12 months post-operatively. Following surgery, patients lost 30% of their initial body weight, along with a 40% decline (p < 0.01) in total triglyceride and a 20% decrease (p < 0.01) in total cholesterol. Levels of cholesterol in the high density lipoprotein (HDL) fraction were unaffected by weight loss, but there was a significant (p < 0.05) increase in the proportion of HDL in its more buoyant and anti-atherogenic form, i.e. HDL-L. The apolipoprotein B-containing lipoproteins, very low density lipoprotein (VLDL), intermediate density lipoprotein (IDL), and low density lipoprotein (LDL), were reduced up to 70% following surgery. There were no significant changes in VLDL or IDL particle composition, i.e. cholesterol/triglyceride, cholesterol/protein, but there was a significant (p < 0.01) increase in the ratio of cholesterol/apolipoprotein B in LDL, suggesting a shift from the small, dense atherogenic LDL to a larger, less atherogenic particle. We conclude that weight loss following gastric bypass surgery markedly improves the lipid-lipoprotein status of morbidly obese premenopausal females and, thereby, significantly reduces the risk of coronary disease.     

Relationship between Obstructive Sleep Apnea and Liver Abnormalities in Morbidly Obese Patients: A Prospective Study

Background Morbid obesity is a risk factor of nonalcoholic steatohepatitis (NASH). Obstructive sleep apnea (OSA) could also be an independent risk factor for elevated liver enzymes and NASH. The relationships between liver injuries and OSA in morbidly obese patients requiring bariatric surgery were studied prospectively. Methods Every consecutive morbidly obese patient (BMI ≥40 kg/m² or ≥35 kg/m² with severe comorbidities) requiring bariatric surgery was included between January 2003 and October 2004. Polygraphic recording, serum aminotransferases (ALT, AST), γ-glutamyltransferase (GGT) and liver biopsy were systematically performed. OSA was present when the apnea–hypopnea index (AHI) was >10/h. Results 62 patients (54 F; age 38.5 ± 11.0 (SD) yrs; BMI 47.8 ± 8.4 kg/m²) were included. Liver enzymes (AST, ALT or GGT) were increased in 46.6%. NASH was present in 34.4% and OSA in 84.7%. Patients with OSA were significantly older (P = 0.015) and had a higher BMI (P = 0.003). In multivariate analysis, risk factors for elevated liver enzymes were the presence of OSA and male sex.The presence of NASH was similar in patients with or without OSA (32.7% vs 44.4% of patients, P = 0.76). Conclusion In this cohort of morbidly obese patients requiring bariatric surgery, one-third of patients had NASH, a prevalence similar to previous studies. OSA was found to be a risk factor for elevated liver enzymes but not for NASH.     

Vertical Banded Gastroplasty Versus Standard or Distal Roux-en-Y Gastric Bypass Based on Specific Selection Criteria in the Morbidly Obese: Preliminary Results

Background: Predicting successful outcomes after bariatric surgical procedures has been difficult, and the establishment of specific selection criteria has been a subject of ongoing research. In an effort to choose the most appropriate surgical procedure for each patient, we have established a specific set of selection criteria for each procedure based on degree of obesity, preoperative dietary habits, eating behavior, and various metabolic features. Methods: From June 1994 to December 1998, 90 bariatric surgical procedures were performed at the authors' institution by a single surgeon (F.K.) based on specific selection criteria. Vertical banded gastroplasty (VBG) was performed in 35 patients, standard Roux-en-Y gastric bypass (RYGB) in 38 patients, and distal RYGB in 17 patients. All patients were monitored postoperatively 1, 3, 6, and 12 months and once per year thereafter, with an additional visit at 18 months in distal RYGB patients. Results: Early postoperative morbidity (<30 days) did not differ significantly between the three groups and averaged 9% of total patients. Long-term postoperative morbidity (>30 days) included 9 incisional hernias (2 in the VBG group, 5 after RYGB, and 2 in the distal RYGB group). There were 6 cases of staple-line disruption, 4 after VBG and 2 after standard RYGB, 1 of which resulted in stomal ulcer. Early postoperative mortality was 0%, and long-term mortality was 1.1%, which was due to pulmonary embolism in 1 standard RYGB patient on the 65th postoperative day. Average percentage of excess weight loss (%EWL) was 62% the first year, 61% the second year, and 50% the third year in VBG patients, and 63.6%, 65%, and 63.3%, respectively, in standard RYGB patients. In distal RYGB patients, where the patient number was significantly smaller, the %EWL at 1 and 2 years, respectively, was 51% and 53%. The most significant metabolic/nutritional complication was the appearance of hypoproteinemia (hypoalbuminemia) in 1 distal RYGB patient 20 months after surgery, which was corrected by total parenteral nutrition and subsequent increase in dietary protein intake. Significant improvement or resolution of pre-existing comorbid conditions was observed in all patient groups. The postoperative quality of eating, as evaluated by variety of food intake and frequency of vomiting, was significantly better in RYGB patients. Conclusions: These results show that selection of the bariatric surgical procedure to be performed in each patient based on specific criteria leads to acceptable weight loss, improvement in preexisting comorbid conditions, and a high degree of patient satisfaction in most patients. On the basis of our own observations as well as those of others, our selection criteria have become more strict over time and our selection of VBG as the operation of choice increasingly infrequent.     

Influence of a Forced Air Warming System on Morbidly Obese Patients Undergoing Roux-en-Y Gastric Bypass

Background: Hypothermia during and after major abdominal surgery decreases host defenses, increases the incidence of coagulopathy and may alter blood pressure, cardiac contractility and myocardial stability. Methods: We designed a prospective randomized study to compare the benefits of a forced air warming system with warm blanket treatments in minimizing the effects of hypothermia on 64 morbidly obese patients undergoing Roux-en-Y gastric bypass. Results: Patients in the forced air warming group (n = 32) had significantly higher perioperative body core temperature, lower central venous pressure and blood pressure readings, lower incidence of shivering, less blood loss intraoperatively and achieved a higher post anesthesia Aldrete Score than those patients in the warmed blanket group (n = 32). Conclusion: The forced air warming system is safe, cost effective and beneficial in minimizing the undesirable consequences of hypothermia in morbidly obese patients undergoing Roux-en-Y gastric bypass.     

Laparoscopic Vertical Banded Gastroplasty: The Milwaukee Experience

Background: laparoscopic techniques are being developed for bariatric surgery. Methods: eleven morbidly obese patients underwent laparoscopic vertical banded gastroplasty in 1993-1994. Results: average length of hospital stay was 3.9 days, mean operating time was 202 min, and the average hospital charges were $12 800. These numbers were compared to the most recent open gastric bypass patients, where average length of stay was 7.4 days, mean operating time was 105 min, and the average hospital charges were $9800 (adjusted value of $16 700). There were no post-operative complications in the laparoscopically-performed VBG patients. Conclusion: laparoscopic VBG is feasible and cost-saving. Weight loss and long term results await ongoing follow-up.