Laparoscopic Gastric Bypass versus Laparoscopic Adjustable Gastric Banding in the Super-obese: A Comparative Study of 290 Patients

Background: Controversy exists regarding the best surgical treatment for super-obesity (BMI >50 kg/m 2 ). The two most common bariatric procedures performed worldwide are laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGBP). We undertook a retrospective single-center study to compare the safety and efficacy of these two operations in super-obese patients. Methods: 290 super-obese patients underwent laparoscopic bariatric surgery: 179 LAGB and 111 LRYGBP. Results: There were one death in both groups. The early complication rate was higher in the LAGB group (10% vs 2.8%, P<0.01). Late complication rate was higher in the LAGB group (26% vs 15.3%, P<0.05). Operating time and hospital stay were significantly higher in the LRYGBP group. LRYGBP had significantly better excess weight loss than LAGB (63% vs 41% at 1 year, and 73% vs 46% at 2 years), as well as lower BMI than LAGB (35 vs 41 at 18 months). Conclusion: LRYGBP results in significantly greater weight loss than LAGB in super-obese patients, but is associated with a higher early complication rate.     

Psoriasis Remission after Laparoscopic Roux-En-Y Gastric Bypass for Morbid Obesity

Background: Psoriasis is a chronic skin disease characterized by epithelial hyperplasia and an accelerated rate of epithelial turnover affecting approximately 1-3% of the population. Exogenous and endogenous factors including morbid obesity can increase the morbidity of psoriasis. Case Report: A 55-year-old male, who weighed 131 kg with BMI 41 kg/m², underwent laparoscopic Roux-en-Y gastric bypass (LRYGBP). He had a 15-year duration of severe psoriasis and was being medically treated. At 12 months after LRYGBP, he had lost 39 kg (68% EWL), and had complete resolution of the psoriasis and had discontinued all preoperative medications related to the disease. At 2 years after LRYGBP, psoriasis has not recurred. Conclusion: Weight loss after LRYGBP should be considered as a strategy in the treatment of severe psoriasis in morbidly obese patients.     

The Surgical Treatment of Type II Diabetes Mellitus: Changes in HOMA Insulin Resistance in the First Year Following Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) and Laparoscopic Adjustable Gastric Banding (LAGB)

Background  Bariatric operations significantly improve glucose metabolism, decrease insulin resistance, and lead to clinical resolution of type II diabetes mellitus in many patients. The mechanisms that achieve these clinical outcomes, however, remain ill defined. Moreover, the relative impact of various operations on insulin resistance remains vigorously contested. Consequently, the purpose of this study was to compare directly the impact of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic adjustable gastric banding (LAGB) on hemoglobin A1c (HbA1c) levels and insulin resistance in comparable groups of morbidly obese patients. Methods  Data were entered prospectively into our bariatric surgery database and reviewed retrospectively. Patients selected operations. Principle outcome variables were percent excess weight loss (%EWL), HbA1c, and homeostatic model assessment for insulin resistance (HOMA IR). Results  The number of follow-up visits for 111 LAGB patients was 263 with a median of 162 days (17–1,016) and 291 follow-up visits for 104 LRYGB patients for a median of 150 days (8–1,191). Preoperative height, weight, body mass index, age, sex, race, comorbidities, fasting glucose, insulin, HbA1c, and HOMA IR were similar for both groups. In particular, the number of patients who were diabetics and those receiving insulin and other hypoglycemic agents were similar among the two groups. The LAGB patients lost significantly less weight than the LRYGB patients (24.6% compared to 44.0% EWL). LAGB reduced HbA1c from 5.8% (2–13.8) to 5.6% (0.3–12.3). LRYGB reduced HbA1c from 5.9% (2.0–12.3) to 5.4% (0.1–9.8). LAGB reduced HOMA IR from 3.6 (0.8–39.2) to 2.3 (0–55) and LRYGB reduced HOMA IR from 4.4 (0.6–56.5) to 1.4 (0.3–15.2). Postoperative HOMA IR correlated best with %EWL. Indeed, regression equations were essentially identical for LAGB and LRYGB for drop in %EWL versus postoperative HOMA IR. Conclusion  Percent excess weight loss significantly predicts postoperative insulin resistance (HOMA IR) during the first year following both LRYGB and LAGB.     

Laparoscopic Roux-En-Y Gastric Bypass is a Safe and Effective Operation for the Treatment of Morbid Obesity in Patients Older than 55 Years

Background: Bariatric surgery in patients >50 years has been controversial. We investigated the safety and efficacy of laparoscopic Roux-en-Y gastric bypass (LRYGBP) in patients >55 years of age. Methods: Prospective data on 71 patients (54 females and 17 males) undergoing LRYGBP were reviewed. The patients were followed for a mean of 17 months (range 2-35 months). Results: The mean age was 59 years (range 55-67 years), and the mean preoperative BMI was 50.2 kg/m² (range 37-65 kg/m²). There were no conversions to open technique. Mean percent of excess weight loss (%EWL) was 20%, 48%, 64% and 67% at 1, 6, 12 and 24 months respectively. 89% of patients had at least a 50% EWL at 1 year postoperatively. There was a significant decrease in the number of patients requiring medical treatment for co-morbidities associated with morbid obesity: diabetes mellitus 87%, hypertension 70% and sleep apnea 86%. There was no inpatient mortality. 1 patient died suddenly 2 weeks postoperatively of possible myocardial infarction or pulmonary embolism. 16 patients developed 22 complications. The median length of hospital stay was 3 days. Conclusion: LRYGBP is a safe and well-tolerated surgical option for the treatment of morbid obesity in patients >55 years old. These patients demonstrate a satisfactory weight loss and resolution of co-morbidities.     

Laparoscopic Conversion of Laparoscopic Gastric Banding to Roux-en-Y Gastric Bypass: a Review of 70 Patients

Background: The feasibility and outcomes of conversion of laparoscopic adjustable gastric banding (LAGB) to laparoscopic Roux-en-Y gastric bypass (LRYGBP) was evaluated. Methods: From November 2000 to March 2004, all patients who underwent laparoscopic conversion of LAGB to LRYGBP were retrospectively analyzed. The procedure included adhesiolysis, resection of the previous band, creation of an isolated gastric pouch, 100-cm Roux-limb, side-to-side jejuno-jejunostomy, and end-to-end gastro-jejunostomy. Results: 70 patients (58 female, mean age 41) with a median BMI of 45±11 (27-81) underwent attempted laparoscopic conversion of LAGB to an RYGBP. Indications for conversion were insufficient weight loss or weight regain after band deflation for gastric pouch dilatation in 34 patients (49%), inadequate weight loss in 17 patients (25%), symptomatic proximal gastric pouch dilatation in 15 patients (20%), intragastric band migration in 3 patients (5%), and psychological band intolerance in 1 patient. 3 of 70 patients (4.3%) had to be converted to a laparotomy because of severe adhesions. Mean operative time was 240±40 SD min (210-280). Mean hospital length of stay was 7.2 days. Early complication rate was 14.3% (10/70). Late major complications occurred in 6 patients (8.6%). There was no mortality. Median excess body weight loss was 70±20%. 60% of patients achieved a BMI of <33 with mean follow-up 18 months. Conclusion: Laparoscopic conversion of LAGB to RYGBP is a technically challenging procedure that can be safely integrated into a bariatric treatment program with good results. Short-term weight loss is very good.     

Revision of Failed Laparoscopic Adjustable Gastric Banding to Roux-en-Y Gastric Bypass

Background: The most common bariatric surgical operation in Europe, laparoscopic adjustable gastric banding (LAGB), is reported to have a high incidence of long-term complications. Also, insufficient weight loss is reported. We investigated whether revision to Roux-en-Y gastric bypass (RYGBP) is a safe and effective therapy for failed LAGB and for further weight loss. Methods: From Jan 1999 to May 2004, 613 patients underwent LAGB. Of these, 47 underwent later revisional Roux-en-Y gastric bypass (RYGBP). Using a prospectively collected database, we analyzed these revisions. All procedures were done by two surgeons with extensive experience in bariatric surgery. Results: All patients were treated with laparoscopic (n=26) or open (n=21) RYGBP after failed LAGB. Total follow-up after LAGB was 5.5±2.0 years. For the RYGBP, mean operating time was 161±53 minutes, estimated blood loss was 219±329 ml, and hospital stay was 6.7±4.5 days. There has been no mortality. Early complications occurred in 17%. There was only one late complication (2%) – a ventral hernia. The mean BMI prior to any form of bariatric surgery was 49.2±9.3 kg/m², and decreased to 45.8±8.9 kg/m² after LAGB and was again reduced to 37.7±8.7 kg/m² after RYGBP within our follow-up period. Conclusion: Conversion of LAGB to RYGBP is effective to treat complications of LAGB and to further reduce the weight to healthier levels in morbidly obese patients.     

Feasibility of Laparoscopic Sleeve Gastrectomy as a Revision Procedure for Prior Laparoscopic Gastric Banding

Background: Laparoscopic sleeve gastrectomy (LSG), initially described by Gagner's group as the first stage of the laparoscopic duodenal switch in super-obese patients, is now gaining wide diffusion among bariatric surgeons as a new restrictive operation. Methods: From January 2005 to January 2006, 8 obese patients with BMI 37-74 kg/m² underwent LSG for conversion from a prior complicated or failed laparoscopic adjustable gastric banding (LAGB). Three patients had severe symptomatic esophageal dilation, while 5 patients had unsuccessful weight loss with poor "band compliance". After de-banding, LSG was calibrated upon a 34-Fr gastric bougie, and blue and green linear staplers were used. The staple-line was buttressed by placing a sero-serosal running suture in all but one patient, and methylene blue dye was used to test for leaks. All the patients underwent upper GI series with water-soluble contrast medium 2 days after the surgery. Results: The average operating-time for LSG was 90 minutes (range 60-120 min). The average hospital stay was 4 days (range 3-7). There were no perioperative complications, no conversion, and no mortality. No intraoperative or postoperative blood transfusions were required. Conclusions: LSG proved to be feasible and safe after LAGB. Longer follow-up and larger series are needed to assess weight loss results.     

Patient Characteristics Impacting Excess Weight Loss following Laparoscopic Adjustable Gastric Banding

Background: Weight loss is more variable after laparoscopic adjustable gastric banding (LAGB) than after gastric bypass. Subgroup analysis of patients may offer insight into this variability. The aim of our study was to identify preoperative factors that predict outcome. Methods: Demographics, co-morbid conditions and follow-up weight were collected for our 1st 200 LapBand ? patients. Linear regression determined average %EWL. Logistic regression analysis identified factors that impacted %EWL. Result: 200 patients returned for 778 follow-up visits. Median age was 44 years (21-72) and median BMI 45 kg/m² (31-76). 140 (80%) were women. Average %EWL was y % = 0.007 %/day (days since surgery) + 0.12% (correlation coef. 0.4823; P<0.001). %EWL at 1 year was 37%. The best-fit logistic regression model found 7 factors that significantly changed the odds of achieving average %EWL. Older patients, diabetic patients and patients with COPD had greater odds of above average %EWL. Female patients, patients with larger BMIs, asthmatic patients and patients with hypertension had increased odds of below average %EWL. Conclusion: Specific patient characteristics and comorbid conditions significantly altered the odds of achieving satisfactory %EWL following gastric banding.     

Gastrointestinal Quality of Life after Laparoscopic Roux-en-Y Gastric Bypass

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a commonly performed bariatric surgical procedure for the treatment of morbid obesity (MO). Obesity-related co-morbidities reduce the quality and expectancy of life. We assessed gastrointestinal quality of life in patients following LRYGBP. Methods: The Gastrointestinal Quality of Life Index (GIQLI test) was used in this study. A higher score correlates with better quality of life. The GIQLI test was administered to 3 non-selected groups: 100 morbidly obese patients (MO group), 100 patients who had undergone LRYGBP (LRYGBP group); and a control group of 100 individuals (CO group). The CO group was composed of healthy individuals with a BMI <30 kg/m², consecutively recruited among the companions of patients who came for a surgery consultation for obesity or other pathologies. Overall test and specific dimensions scores were evaluated for each group. Results: Overall test and specific dimensions scores were significantly lower in patients with MO when compared to the CO and LRYGBP groups. There were no differences between the CO and LRYGBP groups in the overall score with regard to disease-specific digestive symptoms and the psychological and social dimensions. Conclusions: The quality of life of morbidly obese patients is worsened not only because of the presence of digestive symptoms but also because of their emotional, physical and social impact. Patients operated on by LRYGBP experience an improvement in their quality of life, with good tolerance of the anatomical changes.     

Laparoscopic Adjustable Gastric Banding versus Open Vertical Banded Gastroplasty: A Prospective Randomized Trial

Background: Laparoscopic adjustable gastric banding (LAGB) and open vertical banded gastroplasty (VBG) are treatment modalities for morbid obesity. However, few prospective randomized clinical trials (RCT) have been performed to compare both operations. Methods: 100 patients (50 per group) were included in the study. Postoperative outcomes included hospital length of stay (LOS), complications, percent excess weight loss (%EWL), BMI and reduction in total comorbidities. Follow-up in all patients was 2 years. Results: LOS was significantly shorter in the LAGB group. 3 LAGB were converted to open (1 to gastric bypass). Directly after VBG, 3 patients needed relaparotomies due to leakage, of which one (2%) died. After 2 years, 100% follow-up was achieved. BMI and %EWL were significantly decreased in both groups but significantly more in the VBG group compared to the LAGB group (31.0 kg/m² and 70.1% vs 34.6 and 54.9% respectively). Co-morbidities significantly decreased in both groups in time. 2 years after LAGB, 20 patients needed reoperation for pouch dilation/slippage (n=12), band leakage (n=2), band erosion (n=2) and access-port problems (n=4). In the VBG group, 18 patients needed revisional surgery due to staple-line disruption (n=15), narrow outlet (n=2) or insufficient weight loss (n=1). Furthermore, 8 VBG patients developed an incisional hernia. Conclusion: This RCT demonstrates that, despite the initial better weight loss in the VBG group, based on complication rates and clinical outcome, LAGB is preferred. It had a shorter LOS and less postoperative morbidity.     

Results after Laparoscopic Adjustable Gastric Banding in Patients Over 55 Years of Age

Background: Laparoscopic adjustable gastric banding (LAGB) has become the most popular bariatric intervention in Europe. International guidelines recommended age limits for bariatric surgery of 18-60 years. The aim of this study was to evaluate the immediate results in morbidly obese patients >55 years old, treated with LAGB. Methods: Between January 1996 and January 2004, 350 patients underwent LAGB. 24 (6.8%) were >55 years old (Group A), mean age 58.6±3.3 years, mean preoperative BMI 42.3±4.5 kg/m². A comparative randomized analysis with 24 patients younger than age 55 years was performed (Group B: mean age 41.2±9.6 years, mean BMI 42.1±3.6 kg/m²). Baseline clinical features, operative parameters and postoperative results were evaluated. Results: No perioperative complications were recorded. Conversion rate and mortality were nil. Major postoperative complications occurred in 2 patients (8.3%) from Group A (1 intragastric prosthesis migration, 1 pouch dilatation) and 2 patients (8.3%) from Group B (intragastric migrations). Reoperation was needed in 3 cases, and one erosion (Group B) is on the waiting list for removal. Minor complications: 1 port infection in each group required ambulatory port substitution; 1 intraperitoneal portcatheter disconnection (Group B) was successfully treated laparoscopically. Mean follow-up was 31.7 months (Group A) and 33.0 months (Group B). Mean postoperative BMI at 12 and 24 months was 35.9±4.2 and 33.8±4.9 for Group A, and 33.8±4.6 and 33.2±6.0 for Group B. Conclusion: There have been no significant differences in results between the 2 groups. LAGB has been safe and effective in patients >55 years old.     

Laparoscopic Gastric Re-Banding versus Laparoscopic Gastric Bypass as a Rescue Operation for Patients with Pouch dilatation

Background:The authors assessed whether laparoscopic rebanding or laparoscopic Roux-en-Y gastric bypass (LRYGBP) is the best approach for failed gastric banding after pouch dilatation. Methods: Between January 2000 and June 2005, 489 patients underwent laparoscopic gastric banding, and of these, 33 (6.7%) required rescue procedures for pouch dilatation. Each reoperated patient was contacted to obtain information about their postoperative course. Additionally, preoperative weight and BMI, weight loss at 1 year postoperatively, weight at time of pouch dilatation and the time-period between the primary operation and pouch dilatation were analyzed. Results: The most common operation for pouch dilatation was band repositioning or rebanding (16 patients). Band removal without replacement was performed in 7 patients. 8 patients underwent conversion to a LRYGBP. 1 patient underwent laparoscopic gastric sleeve resection and 1 patient received an intragastric balloon. Patients who underwent conversion to LRYGBP are very content and, although weight loss has been nearly the same as after gastric banding, they would prefer the gastric bypass operation to the gastric banding. Conclusion: Conversion to LRYGBP appears to offer significant advantages, and appears to be the rescue therapy of choice after failed laparoscopic gastric banding.     

Laparoscopic Adjustable Gastric Banding: Weight Loss,Co-morbidities,Medication Usage and Quality of Life at One Year

Background: The objective of this study was to determine the weight loss, changes in co-morbidities, medication usage and general health status at 1 year after laparoscopic adjustable gastric banding (LAGB). Methods: Prospective data were obtained from all subjects undergoing LAGB. These measurements included a medical history and review of systems, medications, height and weight and the SF-36 general health survey. Patients were seen for band adjustments as needed throughout the year. At the 1-year follow-up visit, patients were weighed and interviewed about the status of their health conditions and their current medications, and the SF-36 was repeated. Results: Between November 2002 and November 2003, 195 patients had LAGB. The majority of subjects were female (82.8%), married (65.1%), and white (94.9%). Complications occurred in 18 subjects (9.2%). These included 3 slipped bands (1.5%), 4 port problems (2.1%), 8 patients with temporary stoma occlusion (4.1%), 1 explantation (0.5%), and 1 mortality (0.5%). Mean BMI decreased from 45.8 kg/m² (± 7.7) to 32.3 kg/m² (± 7.0). Mean percent excess body weight lost was 45.7% (± 17.1) during the first year. Major improvements occurred in arthritis, asthma, depression, diabetes, gastro-esophageal reflux disease, hyperlipidemia, hypertension, joint and back pain, sleep apnea and stress incontinence. Medication usage declined remarkably. Quality of life (QoL) by the SF-36 showed highly significant improvements. Conclusions: At 1 year after LAGB, patients had experienced significant weight loss, resolution of comorbidities, decreases in medication usage, and improvements in QoL.     

Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity: Results of our Learning Curve in 100 Consecutive Patients

Background: Morbid obesity requires life-long treatment, and bariatric surgery provides the best results. Among the bariatric procedures, laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been considered to be superior. However, it requires advanced laparoscopic skills and a learning curve. We analyzed our results in an initial series of 100 patients. Methods: Data of 100 consecutive patients who underwent LRYGBP for morbid obesity in a 2.5-year period were prospectively collected and analyzed with emphasis on results and complications. Results: Mean age was 31±5 years. There were 63 woman and 37 men. Preoperative BMI was 50±9 kg/m². 33 patients were considered super-obese (BMI>50). Mean operative time was 3.8 ± 0.7 hours. Two patients required conversion to open surgery. Mean hospital stay was 6 days. Complications occurred in 10 patients. Mortality rate was 2%. Excess body weight loss was as follows: 33 ± 8% at 3 months (n=92), 47 ± 2% at 6 months (n=82), 62 ± 4% at 1 year (n= 70), 66 ± 5% at 18 months (n= 63) and 67 ± 8% at 2 years (n= 35). There was significant improvement in several co-morbid conditions, such as diabetes and hypertension. Conclusion: LRYGBP is a reproducible technique. It requires the combination of bariatric and laparoscopic expertise.     

Jejunojejunal Anastomotic Obstruction Following Laparoscopic Roux-en-Y Gastric Bypass Due to Non-Absorbable Suture: A Report of Seven Cases

Introduction: Small bowel obstruction (SBO) is a well-known complication of laparoscopic Roux-en-Y gastric bypass (LRYGBP). We describe 7 cases of jejunojejunal anastomotic obstruction related to adhesion formation after closure of the mesenteric "leaves" defect with non-absorbable suture. Methods: All patients undergoing LRYGBP from October 2002 until February 2005 were entered into a prospective, longitudinal database. All patients who subsequently presented with SBO were analyzed. Results: Jejunojejunal anastomotic obstruction occurred in 7 out of 152 patients (4.6%) in whom LRYGBP was performed from October 2002 to February 2004. Since February 2004, the suture used to close the jejunojejunal mesenteric leaves defect was changed from non-absorbable Dacron (Surgidac^™) to absorbable suture material. The mean interval between initial LRYGBP and subsequent SBO was 153 days. Operative findings common to all 7 cases were dilated loops of proximal small bowel, and a single adhesion just distal to the Roux-Y anastomosis. Following adhesiolysis, each patient had prompt return of bowel function without recurrence of obstruction. Of the 156 patients who have since undergone LRYGBP, none have presented with SBO, and this difference is statistically significant (P=0.008). Conclusions: The overall rate of SBO (2.3%) is consistent with the previous literature, although the incidence of adhesions specifically at the jejunojejunal anastomosis is higher than that previously encountered. It appears that the incidence of postoperative SBO at the jejunojejunal anastomosis is directly linked to the choice of suture material intraoperatively. As such, absorbable suture should be used to close the jejunojejunal mesenteric leaves defect.     

Value of Preoperative Upper Endoscopy in Patients Undergoing Laparoscopic Gastric Bypass

Background: Preoperative evaluation of patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP) has included esophagogastroduodenoscopy (EGD) with little data to substantiate its use. Methods: A retrospective analysis was conducted of patients from Feb 04 to Mar 05 who underwent preoperative EGD and subsequently LRYGBP. Results: 169 patients underwent EGD prior to surgery. Their mean age was 41.1 years (range 14-66), mean BMI 49.7 (range 35-78), and 82% were females. There were no complications from EGD. Significant findings in patients at EGD included gastric ulceration in 3 (2%), duodenal ulcer in 1 (0.7%), Barrett's esophagus in 2 (1.3%), and a GI stromal tumor (GIST) in 1 (0.7%). EGD revealed hiatal hernias in 56 (35.2%), esophagitis in 28 (17%), Schatzki's ring in 5 (3%), gastritis in 43 (27%), gastric polyps in 8 (5%), and duodenitis in 9 (6%). 53 patients (33.3%) had a negative EGD. Ulcer and severe gastritis, esophagitis, and duodenitis diagnosed preoperatively were treated medically before surgery. 9 hiatal hernias were repaired intraoperatively. The patient with the GIST underwent laparoscopic near-total gastrectomy and gastric bypass, while 1 patient with an antral polyp underwent laparoscopic partial gastrectomy in addition to the LRYGBP. Conclusion: EGD is essential for diagnosis of GI diseases including tumors, ulcers, and hiatal hernias that alter the medical and surgical management of patients undergoing gastric bypass.     

Outpatient Laparoscopic Gastric Banding: Initial Experience

Background: Laparoscopic adjustable gastric banding (LAGB) has usually been performed as an inpatient procedure with an average hospital stay of 2-4 days. The aim of this study was to assess the feasibility of LAGB as an ambulatory procedure in selected patients. Methods: Potential candidates for ambulatory LAGB were recruited from patients consulting for obesity surgery. The main inclusion criteria were BMI >35 kg/m² with co-morbid conditions, living within a reasonable distance from the hospital, and adult company at home. The patients were admitted at 0700 hours on the day of surgery, underwent laparoscopic placement of a Lap-Band^? system and were discharged home that evening. Results: 9 women and 1 man underwent outpatient LAGB. Mean age was 36 (range 18-52) years and mean BMI was 38.4 kg/m² (range 35.1-43.3). Co-morbidities included functional dyspnea (6), osteoarthritis (4), arterial hypertension (4), type 2 diabetes (2) and dyslipidemia (1). 7 patients had undergone previous abdominal surgery: cesarian section (4), appendectomy (3), cholecystectomy (1) and hysterectomy (1). All patients had an American Society of Anesthesiologists (ASA) classification of II. The average operating time was 87 minutes (range 65-115). The mean time lapse between the end of the operation and discharge from hospital was 9.6 hours. There were no readmissions, and no complications were noticed at 1 month postoperatively. The patients' satisfaction with the ambulatory LAGB procedure was high. Conclusion: The present study demonstrates that LAGB for obesity may be performed on an ambulatory basis without complications.     

Laparoscopic Gastric Bypass beyond Age 60

Background: Previous reports have questioned the safety and efficacy of gastric bypass in older patients. We examine our results in the older group of patients to shed some light on the appropriateness of offering gastric bypass to senior patients. Methods: A retrospective review of a prospectively collected database on all laparoscopic Roux-en-Y gastric bypass (LRYGBP) cases performed from March 2001 to October 2003 was conducted. Patients >60 years of age were compared to the overall group. Results: A total of 550 patients underwent LRYGBP: all were completed laparoscopically. In the 527 patients <60 years of age, there were no deaths and there were 15 complications (2.8% perioperative morbidity). In the group of patients >60 years old, there were 23 patients; mean age was 64.4 years (60-75 years). There was 1 death in this group (4.3% mortality rate) and 1 postoperative complication (4.3% morbidity rate). In the >60 year group at an average of 12 months follow-up, weight loss was 43.2 kg (28.6-73.2 kg), change in BMI was 16.5 (11-23), and excess weight loss was 65% (40-110%). Also, diabetes resolved in 3 out of 4 patients (75%), obstructive sleep apnea in 2 of 3 (67%), hypercholesterolemia in 3 of 5 (60%) and hypertension resolved or improved in 10 of 11 patients (91%). Conclusion: While patients >60 years of age had a higher morbidity and mortality, their risk/benefit ratio was acceptable. Older patients achieve significant weight loss and resolution of obesity-associated comorbidities.     

Early Gastrointestinal Hemorrhage after Laparoscopic Gastric Bypass

Background: Early gastrointestinal (GI) hemorrhage after open gastric bypass has been infrequently reported. The aim of this study was to examine the incidence of early GI hemorrhage after laparoscopic Roux-en-Y gastric bypass (LRYGBP), its presentation, and possible treatment options. Methods: A retrospective review of 5 patients who developed early postoperative GI hemorrhage after LRYGBP was performed.The charts were reviewed for demographics, clinical presentation, diagnostic evaluation, and treatment. All patients underwent a transected LRYGBP with creation of the gastrojejunostomy anastomosis with a circular stapler and the jejunojejunostomy anastomosis with a linear stapler. Results: Of the 155 patients in our database who underwent LRYGBP, 5 (3.2%) developed early clinical GI hemorrhage. There were 2 males with an average age of 40 years. Clinical presentations of GI hemorrhage were hematemesis (2 patients), bright red blood per rectum (1 patient), melena (1 patient), and hypotension (1 patient). A diagnostic study (nuclear scintigraphy) was performed in only 1 of 5 patients. 3 of 5 patients were managed nonoperatively; 2 patients required fluid and blood resuscitation, and the other patient was managed without blood transfusion. The onset of hemorrhage in these 3 patients occurred 24 hours postoperatively or later. 2 of 5 patients required operative intervention for control of hemorrhage. The onset of hemorrhage or hypotension in these 2 patients occurred within 12 hours after surgery. The sites of hemorrhage were at the gastric remnant staple-lines in 1 patient and at the gastrojejunostomy and gastric remnant staple-lines in the other patient. Conclusion: Early GI hemorrhage is a potential complication after transected LRYGBP. Early reoperative intervention should be performed for patients with hemodynamic instability and patients with early onset of hemorrhage after surgery.     

Preoperative Carbohydrate "Addiction" Does Not Predict Weight Loss after Laparoscopic Gastric Bypass

Background: Weight loss after laparoscopic Roux-en-Y gastric bypass (LRYGBP) varies. Dietary habits that exist preoperatively may continue after surgery and affect weight loss. This study investigated the hypothesis that preoperative carbohydrate addiction would predict weight loss after laparoscopic gastric bypass. Methods: 104 consecutive patients in our LRYGBP program were included in the study. A preoperative survey was used to determine level of carbohydrate craving. This survey was scored from 0 to 60. A higher score indicated a higher level of carbohydrate addiction. Percentage of excess weight loss (%EWL) was determined after at least 1 year postoperatively in all patients. Results: Data were available in 95 (91%) of the patients. There was no correlation seen between level of carbohydrate addiction and %EWL at 1 year (r=0.02; P=NS). In addition, we looked at patients with successful weight loss (>50% %EWL; n=83) versus those patients who were considered unsuccessful (<50% EWL; n=12). There was no statistical difference in the level of preoperative carbohydrate craving between these 2 groups (36±13 vs 33±15; P=NS). Conclusions: Consistently large carbohydrate intake preoperatively does not predict weight loss after LRYGBP. High level of carbohydrate addiction is not a contraindication to LRYGBP.