Reoperative bariatric surgery. Lessons learned to improve patient selection and results.

OBJECTIVE: The purpose of this study was to determine the spectrum of presentation, safety, and efficacy of operative bariatric surgery. SUMMARY BACKGROUND DATA: The only lasting therapy for medically complicated clinically severe obesity is bariatric surgery. Several operative approaches have resulted in disappointing long-term weight loss or an unacceptable incidence of complications that require revisionary surgery. METHODS: Sixty-one consecutive patients who underwent reoperative bariatric surgery from 1985 to 1990 were observed prospectively. One, two, or three previous bariatric procedures had been performed in 77%, 18%, and 5% of patients, respectively. Reoperation was required for unsatisfactory weight loss after gastroplasty or gastric bypass (61%), metabolic complications of jejunoileal bypass (23%), or other complications (16%), including stomal obstruction, alkaline- or acid-reflux esophagitis, and anastomotic ulcer. Revisionary procedures included conversion to vertical banded gastroplasty (33% of operations) and vertical Roux-en-Y gastric bypass (52% of operations); partial pancreato-biliary bypass was used selectively in four patients with severe, medically complicated obesity. RESULTS: A single patient died postoperatively of a pulmonary embolus; serious morbidity occurred in 11%. Weight loss (mean +/- SEM) after reoperation for unsuccessful weight loss was greater with gastric bypass than with vertical banded gastroplasty (54 +/- 6% versus 24 +/- 6% of excess body weight). Metabolic complications of jejunoileal bypass were corrected, but 67% of the patients were dissatisfied with their postoperative lifestyle because of changes in eating habits or weight gain (64% of patients). Stomal complications and esophageal reflux symptoms were reversed in all patients. CONCLUSIONS: Reoperative bariatric surgery in selected patients is safe and effective for unsatisfactory weight loss or for complications of previous bariatric procedures. Conversion to gastric bypass provides more effective weight loss than vertical banded gastroplasty.     

Establishing a laparoscopic gastric bypass program

OBJECTIVE: To evaluate the outcomes for laparoscopic Roux-en-Y gastric bypass in a newly developed bariatric surgery program. METHODS: A prospective analysis of the initial 100 patients who underwent laparoscopic Roux-en-Y gastric bypass at a community based teaching hospital between December 2000 and October 2001 was performed. Study endpoints included operative time, early (less than 7 days) and late complication rates, hospital length of stay (LOS), time to initiation of oral diet, and percentage of excess body weight loss. RESULTS: There were 91 women and 9 men with a mean age of 39 years (range 21 to 57). Mean preoperative weight was 126.4 kg (range 92.3 kg to 214 kg), with a mean preoperative body mass index of 47.4 (range 37.3 to 75.7). Ninety (90%) patients had at least one significant medical comorbidity (median = 6 per patient). Mean operative time was 2.4 hours (range 1.0 to 6.5; 3.0 hours for the first 50 patients and 1.8 hours for the last 50 patients). Three patients required conversion to open gastric bypass, all due to equipment failure (two harmonic scalpel failures and one linear stapler malfunction). Seven patients had early complications, 3 with anastomotic hemorrhage requiring transfusion, 3 with intestinal leaks requiring reoperation, and 1 with transected nasogastric tube. Eleven patients had late complications: 5 patients with small bowel obstruction, all due to herniation through the transverse colon mesentery (these occurred early in the series, prompting a change in technique, with no subsequent occurrences), 3 with gastrojejunostomy strictures requiring endoscopic dilation, 2 superficial wound infections, and 1 port-site incisional hernia. No complications occurred in the last 40 patients. No deaths occurred. Median hospital stay was 2 days (range 1 to 37); 3 days in the first 50 cases and 1 day in the last 50 cases. The median number of days to the start of an oral diet was 1 day. Average excess body weight loss was 34% (median follow-up 4 months). CONCLUSIONS: Laparoscopic Roux-en-Y gastric bypass is a technically challenging procedure that can be safely integrated into a bariatric treatment program with good results. Improved outcomes, shorter operative times, and fewer complications are associated with increased surgical experience.     

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.     

Laparoscopic Sleeve Gastrectomy as an Initial Bariatric Operation for High-Risk Patients: Initial Results in 10 Patients

Background: The outcomes and initial results of laparoscopic sleeve gastrectomy were evaluated. Methods: A prospective study of the initial 10 patients who underwent laparoscopic sleeve gastrectomy (LSG) was performed. Study endpoints included operative time, complication rates, hospital length of stay and percentage of excess weight loss (%EWL). Results: There were 5 women and 5 men, with mean age 43 years (range 31 to 52). Mean preoperative weight was 182 kg (range 125-247 kg), with mean preoperative BMI 64 (range 61-80). Indication for LSG was related to BMI in all patients. 1 patient had previous restrictive bariatric surgery. Mean operative time was 2 hours (range 1.5-2.5). No patient required conversion. There were no postoperative complications nor mortality. Median hospital stay was 7.2 days. Average %EWL and BMI at 1 year were 51% and 23 kg/m², respectively. Conclusion: LSG can be safely integrated into a bariatric surgical program with good results in terms of weight loss and quality of life. LSG can be a firststage procedure before gastric bypass or duodenal switch or a one-stage restrictive procedure if longterm results are good. LSG should be considered as a surgical option in the bariatric field.     

Gastric bypass for morbid obesity: a medical--surgical assessment.

With the operative modifications and dietary guidelines described in this report, death and complications from gastric bypass were minimal, and weight loss was marked. Ninety per cent of a group of 69 patients lost more than half of their excess weight within the first two years after operation. Stringent preselection of patients for operation was crucial to the success of the operation, and marked alterations of eating behavior was necessary to achieve the weight loss. Mild electrolyte deficiencies and hypovitaminosis occurred in up to one-fourth of the patients. While none of these abnormalities was harmful to the patients, and all were easily corrected, their occurrence demonstrates the importance of long-term follow-up after the operation. We conclude that gastric bypass, with a 50-60 cc pouch and a small (1-1.2 cm) gastrojejunostomy, remains the operation of choice for morbid obesity.     

Near-total gastric bypass for morbid obesity

Among 50 morbidly obese patients who underwent gastric bypass, the gastric pouch was made only large enough to permit an anastomosis with the jejunum. Eighteen months after operation, the mean weight loss was 55 kg, and the mean excess weight loss was 70%. One half of the patients had less than 22.7 kg of residual excess weight. The most frequent immediate postoperative complication involved the respiratory tract (ten patients). Staple line failure in three of ten patients who had pouch construction by a single application of staples and iron deficiency anemia in six patients were the most important late complications. Near-total gastric bypass in which the pouch is constructed with two applications of staples is an effective operation for weight control and should virtually eliminate the need for revision caused by staple line failure or for a pouch that is too large.     

Bariatric surgery for severely obese adolescents

A 1991 National Institutes of Health Consensus Conference concluded that severely obese adults could be eligible for bariatric surgery if they had a body mass index (BMI) ≥35 kg/m² with or ≥40 kg/m² without obesity comorbidity. It was thought at that time that there were inadequate data to support bariatric surgery in severely obese adolescents. An estimated 25% of children in the United States are obese, a number that has doubled over a 30-year period. Very little information has been published on the subject of obesity surgery in adolescents. Therefore we reviewed our 20-year database on bariatric surgery in adolescents. Severely obese adolescents, ranging from 12 to less than 18 years of age, were considered eligible for bariatric surgery according to the National Institutes of Health adult criteria. Gastroplasty was the procedure of choice in the initial 3 years of the study followed by gastric bypass, which was found to be significantly more effective for weight loss in adults. Distal gastric bypass (D-GBP) was used in extremely obese patients (BMI ≥60 kg/m²) before 1992 and long-limb gastric bypass (LL-GBP) was used for super-obese patients (BMI ≥50 kg/m²) after 1992. Laparoscopic gastric bypass was used after 2000. Thirty-three adolescents (27 white, 6 black; 19 females, 14 males) underwent the following bariatric operations between 1981 and June 2001: horizontal gastroplasty in one, vertical banded gastroplasty in two, standard gastric bypass in 17 (2 laparoscopic), LL-GBP in 10, and D-GBP in three. Mean BMI was 52 ±11 kg/m² (range 38 to 91 kg/m²), and mean age was 16 ± 1 years (range 12.4 to 17.9 years). Preoperative comorbid conditions included the following: type II diabetes mellitus in two patients, hypertension in 11, pseudotumor cerebri in three, gastroesophageal reflux in five, sleep apnea in six, urinary incontinence in two, polycystic ovary syndrome in one, asthma in one, and degenerative joint disease in 11. There were no operative deaths or anastomotic leaks. Early complications included pulmonary embolism in one patient, major wound infection in one, minor wound infections in four, stomal stenoses (endoscopically dilated) in three, and marginal ulcers (medically treated) in four. Late complications included small bowel obstruction in one and incisional hernias in six patients. There were two late sudden deaths (2 years and 6 years postop-eratively), but these were unlikely to have been caused by the bariatric surgical procedure. Revision procedures included one D-GBP to gastric bypass for malnutrition and one gastric bypass to LL-GBP for inadequate weight loss. Regain of most or all of the lost weight was seen in five patients at 5 to 10 years after surgery; however, significant weight loss was maintained in the remaining patients for up to 14 years after surgery. Comorbid conditions resolved at 1 year with the exception of hypertension in two patients, gastroesophageal reflux in two, and degenerative joint disease in seven. Self-image was greatly enhanced; eight patients have married and have children, five patients have completed college, and one patient is currently in college. Severe obesity is increasing rapidly in adolescents and is associated with significant comorbidity and social stigmatization. Bariatric surgery in adolescents is safe and is associated with significant weight loss, correction of obesity comorbidity, and improved self-image and socialization. These data strongly support obesity surgery for those unfortunate individuals who may have difficulty obtaining insurance coverage based on the 1991 National Institutes of Health Consensus Conference statement. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (oral presentation).     

Laparoscopic Roux-en-Y gastric bypass: minimally invasive bariatric surgery for the superobese in the community hospital setting

Roux-en-Y gastric bypass (RYGB) operation has become a popular choice for weight-reduction surgery. We report an outcome analysis of our early results with laparoscopic Roux-en-Y gastric bypass for superobese (BMI >50) patients. Between January 2000 and October 2001, we operated on 71 superobese patients. The mean body mass index (BMI) of patients at time of surgery was 57 kg/m2. The prospectively collected data included patient demographics, comorbidities, operative times, postoperative weight loss, and complications. Conversion to open gastric bypass was required in one patient. The overall complication rate was 10 per cent. Preoperative comorbidities were resolved or improved in 93 per cent of patients at 1-year postoperative. Average operative time and length of hospital stay were 196 minutes and 2.3 days, respectively. Mean percentage excess weight loss at 3, 6, 9, and 12 months was 27 per cent, 39 per cent, 49 per cent, and 55 per cent, respectively. Mean BMI decreased to 36 kg/m2 over a 12-month period. Laparoscopic Roux-en-Y gastric bypass surgery for superobese patients as performed in the community hospital setting can be both safe and effective with respect to overall postoperative course, early weight loss, and reduction of comorbidity.     

Revision of Failed Gastric Bypass to Distal Roux-en-Y Gastric Bypass: A Review of 65 Cases

Background: No bariatric operation has been documented to effect adequate weight loss in all patients. Patients with inadequate weight loss or significant weight regain with an anatomically intact short-limb gastric bypass, of which the Fobi pouch operation (FPO) for obesity is a modification, are usually revised to a distal Roux-en-Y gastric bypass (DRYGBP) to enhance weight loss. Method: A retrospective review of the charts of all patients who had a revision to a DRYGBP at our Center during an 8-year period was carried out and the findings analyzed. Results: 65 patients who had the FPO had a revision to the DRYGBP.Most were super obese patients who, even though they had lost significant weight, were still morbidly obese. Some were patients who had not lost adequate weight or <40% excess weight, and a small number were patients who requested more weight loss even though they had a BMI of < 35. 15 patients developed protein malnutrition requiring supplemental feeding. 6 required rerevision to short-limb gastric bypass. Conclusion: Revision of short-limb gastric bypass to DRYGBP usually enhances weight loss but at a cost of an increased incidence of protein malnutrition.     

An assessment of vertical banded gastroplasty-Roux-en-Y gastric bypass for the treatment of morbid obesity

OBJECTIVE: To analyze retrospectively the mortality, morbidity, and weight loss of a specific form of gastric bypass for the treatment of morbid obesity. The technique incorporates a small pouch along the lesser curvature of the stomach, an outlet restricted by a nondistensible band and a Roux-en-Y gastric bypass. MATERIAL AND METHODS: We analyzed 652 consecutive patients with no previous bariatric surgery who underwent our present form of gastric bypass. Parameters used to evaluate the technique included mortality, weight loss at 5 years and complications. The operation is a combination of vertical banded gastroplasty and Roux-en-Y gastric bypass (VBG-RGB). The patients followed up to 5 years had an initial weight of 140 kg [range, 94 to 288] and a BMI of 50 [range, 38 to 86]. Superobese individuals (BMI of 60 [range, 48 to 86]) made up 42% of the group. RESULTS: There was an early reoperation rate of 0.5%. The incidence of late complications that required reoperation was 0.5%. There were 2 deaths in the study from pulmonary embolism for a mortality of 0.3%. At 5 years, the patients had lost an average of 58kg [range, 14 to 143] and had a percentage excess weight loss of 77 [range, 32 to 108]. Their BMI was reduced to 29 kg/m(2) [range, 20 to 43] and 93% lost more than 50% of the excess weight. CONCLUSIONS: VBG-RGB is effective in producing superior weight loss in morbid and superobese patients and has a low mortality and morbidity. We recommend this procedure without reservations.     

Bariatric Re-operations: Are They Preventable?

Background: Many operations are currently used for morbid obesity, and every procedure appears to have advantages, drawbacks and failures. Re-operation is a part of bariatric surgery practice that is necessary in the event of failure. We analyzed the reasons for failure in the bariatric re-operation group. Methods: From June 1998 to April 2000, 17 morbidly obese patients had a bariatric re-operation. Of 203 bariatric operations performed in our institution, 12 patients had a re-operation (5.9%), and 5 patients had their primary procedure performed elsewhere. Mean age was 36.5 ±11 years, mean original weight 151.3 ± 44.3 kg, mean BMI 58.4±16.9 kg/m2 and mean excess body weight (EBW) 94.4±43.5 kg. Mean height was 161±7.7 cm, and 15 patients were female (88.2%).The primary bariatric operation was vertical banded gastroplasty (VBG) in 15 patients (88.2%), Roux-en-Y gastric bypass (RYGBP) in 1 patient (5.9%), and gastric banding in 1 patient (5.9%). Duration since the primary surgery was a mean of 15.6 months (range 1-72 months). Results: Reasons for re-operation were inadequate weight loss (47%) or food intolerance (53%). 11 patients had VBG converted to RYGBP,1 patient had a gastric banding converted to a BPD, 4 patients had their VBG converted to a gastro-gastrostomy, and 1 patient had a RYGBP staple dehiscence re-stapled. Conclusion: Incidence of bariatric re-operations may be decreased if super-obese patients, older patients, and sweets-consuming individuals undergo RYGBP or BPD as the primary operation rather than VBG or gastric banding. The use of staplers transecting and separating the gastric pouch from the remaining stomach can decrease staple dehiscence.     

Adjustable Gastric Banding as a Revisional Bariatric Procedure after Failed Gastric Bypass

Background: Inadequate weight loss after proximal gastric bypass presents a clinical challenge to bariatric surgeons. Pouch size, stoma size and limb length are the variables that can be surgically altered. Aside from conversion to distal bypass, which may have significant negative nutritional sequelae, revisional surgery for this group of patients has not often been reported. The addition of adjustable silicone gastric banding (ASGB) to Roux-en-Y gastric bypass (RYGBP) may be a useful revision strategy because it has potential safety benefits over other revisional approaches. Materials and Methods: We report on 8 patients who presented with inadequate weight loss or significant weight regain after proximal gastric bypass. All patients underwent revision with the placement of an ASGB around the proximal gastric pouch. Bands were adjusted at 6 weeks postoperatively and beyond as needed. Complications and weight loss at the most recent follow-up visit were evaluated. Results: Mean age and body mass index (BMI) at the time of revision were 39 ± 9.9 years and 44.0 ± 4.5 kg/m² respectively. No patients were lost to follow-up, and they lost an average of 38.1 ± 10.4% and 44.0 ± 36.3% of excess weight and 49.1 ± 20.9% and 52.0 ± 46.0% of excess BMI in 12 and 24 months respectively. Patients lost an average of 62.0 ± 20.5% of excess weight from the combined surgeries in 67 (48–84) months. The only complication was the development of a seroma overlying the area of the port adjustment in one patient. There have been no erosions or band slippages to date. Conclusions: These results indicate that the addition of an ASGB causes significant weight loss in patients with poor weight loss outcome after RYGBP. The fact that no anastomosis or change in absorption is required may make this an attractive revisional strategy. Long- term evaluation in a larger population is warranted.     

Laparoscopic Swedish Adjustable Gastric Banding: 6-year Follow-up and Comparison to other Laparoscopic Bariatric Procedures

Background: The advantages of laparoscopy over open surgery are well known. The aim of this study was to compare our results with Swedish adjustable gastric banding (SAGB) with other laparoscopically performed bariatric procedures (gastric bypass, LapBand^?, vertical banded gastroplasty). Methods: Between January 1996 and December 2001, 454 patients (381 women, 73 men) underwent laparoscopic SAGB. All data (demographic and morphologic, co-morbidities, operative, and follow-up) were prospectively collected in a computerized databank. Results: Mean follow-up was 30 months (range 1-66). Average total weight loss was 35.5 kg after 1 year, reaching an average total of 54 kg after 3 years. Mean excess weight loss was 72% after 3 years, and the BMI decreased from 46.7 to 28.1 kg/m². Patients with co-morbidities reported marked improvement of their accompanying diseases. Complications requiring reoperation occurred in 7.9%. There was no mortality. The clinical outcome compared with the other laparoscopic bariatric procedures showed no significant difference. Conclusion: All laparoscopically performed bariatric procedures are very promising. The great advantage of laparoscopic adjustable gastric banding is that this operation is minimally invasive to the stomach, totally reversible and adjustable to the patients' needs.     

Outcomes of a Third Bariatric Procedure for Inadequate Weight Loss

Background and Objectives:

The robust volume of bariatric surgical procedures has led to significant numbers of patients requiring reoperative surgery because of undesirable results from primary operations. The aim of this study was to assess the feasibility, safety, and outcomes of the third bariatric procedure after previous attempts resulted in inadequate results.

Methods:

We retrospectively identified patients who underwent a third bariatric procedure for inadequate weight loss or significant weight regain after the second operation. Data were analyzed to establish patient demographic characteristics, perioperative parameters, and postoperative outcomes.

Results:

A total of 12 patients were identified. Before the first, second, and third procedures, patients had a mean body mass index of 67.1 ± 29.3 kg/m², 60.9 ± 28.3 kg/m², and 49.4 ± 19.8 kg/m², respectively. The third operations (laparoscopic in 10 and open in 2) included Roux-en-Y gastric bypass (n = 5), revision of pouch and/or stoma of Roux-en-Y gastric bypass (n = 3), limb lengthening after Roux-en-Y gastric bypass (n = 3), and sleeve gastrectomy (n = 1). We encountered 5 early complications in 4 patients, and early reoperative intervention was needed in 2 patients. At 1-year follow-up, the excess weight loss of the cohort was 49.4% ± 33.8%. After a mean follow-up time of 43.0 ± 28.6 months, the body mass index of the cohort reached 39.9 ± 20.8 kg/m², which corresponded to a mean excess weight loss of 54.4% ± 44.0% from the third operation. At the latest follow-up, 64% of patients had excess weight loss >50% and 45% had excess weight loss >80%.

Conclusion:

Reoperative bariatric surgery can be carried out successfully (often laparoscopically), even after 2 previous weight loss procedures.     

Using the StomaphyX(TM) endoplicator to treat a gastric bypass complication

Background and Objectives:

As the number of bariatric operations performed increases, the number of patients requiring reoperation for failed weight loss is expected to proportionately increase. Natural orifice surgery is an alternative approach to revisional gastric bypass surgery when postoperative complications, such as dilatation of the gastrojejunostomy, gastrogastric fistula, and gastric pouch, dilation occur.

Methods:

The present article reports on the safe and successful use of an endoscopic tissue plicating device in a patient found to have a dilated gastric pouch and a gastrogastric fistula 12 years after an open, nondivided RYGB.

Results:

The procedure was performed without complications and resulted in a reduced pouch size to approximately 30cc to 50cc and redirection of the flow of gastric contents through her gastrojejunostomy. The patient''s early satiety returned and, 1 year postoperatively, she had incurred a 45-pound weight loss.

Discussion:

The morbidity and mortality of revision gastric bypass was avoided while the patient''s goal of moderate weight loss was achieved. Tissue plicating devices offer an alternative for repair of some postbariatric complications. With the rapid advances in endoluminal technology and increasing experience with natural orifice surgery, the ability to successfully address surgical problems through less invasive means will continue to improve.     

Adjustable gastric band placed around gastric bypass pouch as revision operation for failed gastric bypass

BackgroundThe failure rate after gastric bypass surgery for weight loss has been reported at 10–20%. To date, no reliably safe and effective salvage operation is available. This pilot study was conducted to determine whether restriction of the Roux-en-Y gastric bypass (RYGB) pouch using the adjustable gastric band (AGB) is an effective revision operation.MethodsA prospectively accrued group of patients who underwent revisional surgery using the AGB placed around the RYGB pouch by our bariatric surgical group from October 2004 to October 2006 was analyzed.ResultsOf the 10 patients accrued during this period, 2 were lost to follow-up, leaving 8 patients for analysis. Of the 8 patients, 1 was a man and 7 were women. The mean prerevision weight was 135.75 kg (range 105–165), and the body mass index was 48.42 kg/m² (range 38.92–55). The mean weight loss at 1 year of follow-up was 17.03 kg (range 0.2–42), with a mean percentage of excess weight loss of 24.29% (range 0.2–49.2%). The mean weight loss of the 5 patients with 2 years of follow-up was 36.4 kg (range 20–58), with a mean percentage of excess weight loss of 48.7% (range 21.8–98.1%). One patient with 3 years of follow-up had a weight loss of 56 kg and a percentage of excess weight loss of 66.2%. Three minor complications developed: 2 AGB port-related complications requiring port revision and 1 postoperative wound hematoma requiring evacuation. No band erosions or band slippages occurred, and no major complications developed.ConclusionIn our study, an AGB placed around the RYGB pouch was a safe and effective revision operation for a failed RYGB operation.     

Continued Excellent Results with the Mini-Gastric Bypass: Six-Year Study in 2,410 Patients

Background: There is a growing body of evidence showing that the Mini-Gastric Bypass (MGB) is a safe and effective alternative to other bariatric surgical operations. This study reports on the results of a consecutive cohort of patients undergoing the MGB. Methods: A prospective database was used to continuously assess the results in 2,410 MGB patients treated from September 1997 to February 2004. Results:The average operative time was 37.5 minutes, and the median length of stay was 1 day. The 30-day mortality and complication rates were 0.08% and 5.9% respectively. The leak rate was 1.08%. Average weight loss at 1 year was 59 kg (80% of excess body weight). The most frequent long-term complications were dyspepsia and ulcers (5.6%) and iron deficiency anemia (4.9%.) Excessive weight loss with malnutrition occurred in 1.1%. Weight loss was well maintained over 5 years, with <5% patients regaining more than 10 kg. Conclusions: Overall, the MGB is very safe initially and in the long-term. It has reliable weight loss and complications similar to other forms of gastric bypass.     

Vertical Banded Gastroplasty--Gastric Bypass: preliminary report

Vertical banded gastroplasty-gastric bypass is a surgical technique combining the advantages of the vertical banded gastroplasty with those of gastric bypass. The procedure was performed on 148 morbidly obese individuals: 83% were female and 17% were male. Ages ranged from 15 to 64 years, with a mean age of 35. Mean percentage weight was 215% of ideal. The vertical banded gastroplasty is constructed by creating a 10 cc vertical pouch along the lesser curvature with a 5.5 cm supporting band. The pouch is fashioned in a way that the lower portion is free and mobile. This free segment of stomach is anastomosed by triangulation to a Roux-en-Y loop of jejunum, which is brought up in a retrocolic, retrogastric fashion. With 100% follow-up in the 19 patients who have reached 1 year, average excess weight loss has been substantial. There was one early postoperative complication requiring surgery. Two patients required late revisional operations. Vertical banded gastroplasty-gastric bypass is a relatively simple procedure to perform and has a low rate of complications. Gastric bypass in combination with a small banded pouch along the lesser curvature should result in substantial and permanent weight loss.     

Laparoscopic Sleeve Gastrectomy as Treatment for Morbid Obesity: Technique and Short-Term Outcome

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) and laparoscopic adjustable gastric banding (LAGB) are the most commonly performed surgical procedures for weight reduction in the United States. Currently, laparoscopic sleeve gastrectomy (LSG) is being explored. The aim of this study was to assess the safety and short-term efficacy of LSG as a treatment option for weight reduction. Methods: Data of all patients who underwent LSG for treatment of morbid obesity between November 2004 and March 2006 and completed the 3- and 6-month follow-up visits at the time of the study, were retrospectively reviewed. Data collected included demographics, operative time, length of stay, postoperative complications, and degree of weight reduction. Results: Of the 62 patients who underwent LSG performed by two surgeons, the data of 30 patients (7 males and 23 females) were further analyzed. Mean preoperative BMI was 41.4 (33-59) kg/m². Mean operative time was 80 min (range 65-130). Mean hospital stay was 3.2 days (range 2 to 25). Mean weight loss at 3 and 6 months following the procedure was 22.7 kg and 30.5 kg respectively, and mean % excess weight loss (EWL) was 40.7 and 52.8, respectively. Three patients were considered to have mild complications, and one patient had a major complication that necessitated surgical intervention. There was no mortality. Conclusions: In the short-term, LSG is a safe and effective treatment option.