Comparison of 21 vs. 25 mm Gastrojejunostomy in the Gastric Bypass Procedure - Early Results

Background: Many bariatric surgeons consider a small gastrojejunostomy stoma critical to the success of gastric bypass. Methods:We retrospectively compared a 21 vs. 25 mm gastrojejunostomy in 50 patients undergoing gastric bypass for morbid obesity. Results: 31 patients were constructed with a 21mm EEA, group I, and 19 with a 25 mm, group II. Average percent of excess body weight lost was 61%, 65%, and 64% at 12, 15, and 18 months followup in the group I patients, vs. 61%, 67%, and 69% in the group B patients. Differences were not significant. Complaints of nausea, vomiting, and/or dysphagia were similar between the groups. Conclusion:The choice of a 21 or 25 mm gastrojejunostomy does not appear to alter the success of gastric bypass surgery and can be based upon surgeon preference.     

Variables Affecting BMI Evolution at 2 and 5 Years after Vertical Banded Gastroplasty

Background: Vertical banded gastroplasty (VBG) has been found to result in significant reduction in body mass index (BMI) during the first postoperative year.We investigated the impact of some intrinsic and extrinsic factors on long-term BMI evolution in morbidly obese patients who underwent VBG, with the aim of establishing a long-term weight-loss prognosis. Methods: 67 consecutive morbidly obese patients who underwent VBG were followed for 2 years; of these, 34 were followed 3 more years, for a total follow-up of 5 years. BMI was monitored and correlated with demographic (preoperative BMI, obese relatives, age and gender) and lifestyle variables (physical activity, habitual dietary transgression and occupational status). Results: Global BMI fell from 47.5 at the time of the intervention to 32.1 when patients were examined 12 months after surgery. From the second year, an upward trend was observed, and at 5 years, mean BMI was above 35, considered in the high-risk range. Modifiable variables affecting lifestyle have shown significantly favorable effects on BMI evolution. Among intrinsic variables, BMI before surgery and obese parents also affect long-term evolution. Conclusion: Different variables should be considered in order to establish a long-term weight-loss prognosis for each patient, thus making it possible to act more specifically on modifiable variables.     

Intragastric Balloons for Preoperative Weight Reduction

Background: If medical treatment of obesity fails and if surgical gastroplasty is not indicated, insertion of an intragastric balloon may represent an intermediate modality. Methods: Two patients are reported in whom a balloon was placed for weight reduction before elective surgery: 1) A 53-year-old woman with a BMI of 41.3 kg/m² lost 18 kg in 6 months and then underwent surgical repair of a huge incisional hernia; 2) A 58- year-old woman with a BMI of 35.8 kg/m² had total hip arthroplasty after losing 15.5 kg in 5 months. Results: The uneventful postoperative recovery in both patients was thought to be positively influenced by their preoperative weight loss. Conclusion: In morbidly obese patients, intragastric balloon placement may contribute to preoperative weight reduction before elective surgery.     

A Rare Complication of Adjustable Gastric Banding:Wernicke's Encephalopathy

Background:Wernicke'sencephalopathy is an uncommon complication seen after morbid obesity surgery. Neurological and cardiac symptoms can occur. Early and adequate replacement of thiamin is crucial. Methods: A patient, who was operated by adjustable silicone gastric banding had severe vomiting 1 week after the operation. Physical examination showed no abnormalities except neurological signs consisting of ataxia, disorientation and diplopia. All radiological and biochemical parameters were in the normal range. Result: After replacement of vitamin B₁ (thiamin) intravenously 20 mg twice daily, all the neurological signs regressed day by day. Oral thiamin pills have been continued. Conclusion: Wernicke's encephalopathy which occurs as a result of thiamin deficiency is a rare complication that has serious morbidity with rapidly progressing neurologic symptoms, and must be treated immediately. Surgeons who treat morbidly obese patients must follow the metabolic and nutritional status of the patient.     

Hepatic Portal Gas due to Gastro-jejunal Anastomotic Leak after Laparoscopic Gastric Bypass

Gastrointestinal complications after laparoscopic Roux-en-Y gastric bypass (LRYGBP) are not uncommon. Leakage of the gastro-jejunal anastomosis is the main early surgical complication of LRYGBP. Hepatic portal venous gas (HPVG) has been described in association with a variety of pathologic conditions. HPVG is a potentially life-threatening condition due to its etiology, with a global survival rate of <25%. We present a case of gastro-jejunal anastomotic leak associated with HPVG after LRYGBP.     

Development of Acute Gouty Attack in the Morbidly Obese Population after Bariatric Surgery

Background: Gout is associated with increased body weight. We evaluated the prevalence of gout and acute gouty attacks in the morbidly obese population who underwent bariatric surgery. Methods: The medical records and operative reports of 1,240 patients who underwent bariatric surgery were reviewed retrospectively for weight parameters, BMI, weight loss, medical history of gout, and onset of acute gouty attacks. Results: Of the 1,240 patients, 5 (0.4%) had been previously diagnosed with gout. 2 of these 5 had acute attacks during the postoperative period, and responded succesfully to intravenous colchicine. Conclusion: Although rare, gout must be considered a co-morbid illness in obese and morbidly obese patients. Surgeons should be familiar with the signs and symptoms of attacks in the postoperative period, and be knowledgeable in the management.     

Alterations in T-Cell Subset Frequency in Peripheral Blood in Obesity

Background: Obesity affects the regulation of immune and inflammatory responses. This study characterizes differences in peripheral blood lymphocyte phenotype in obese humans. Methods: Frequencies of lymphocyte subsets among peripheral blood mononuclear cells were compared between 10 obese (BMI ≥35) and 10 lean subjects, as determined by antibodies directed against cluster differentiation (CD) markers. Results: Obese patients demonstrated an increased frequency of CD3+CD4+ T-cells (mean difference 12%, P=0.004), a decreased frequency of CD3+CD8+ T-cells (mean difference 9.4%, P=0.016) and an increased frequency of CD3+CD8+CD95+ T-cells (mean difference 13.3%, P=0.032). No other differences among T-cell or monocyte subsets were noted. Conclusions: Obesity is associated with alterations in frequencies of peripheral CD4+ and CD8+ T-cells and aberrations in the expression of CD95 among CD8+ T-cells. These data suggest both CD4+ and CD8+ T-cell compartments, as well as the regulation of CD95 expression on CD8+ T-cells, as targets for further study into obesity's effects on the immune system.     

Continuous Positive Airway Pressure (CPAP) Changes in Bariatric Surgery Patients Undergoing Rapid Weight Loss

Background: Obstructive sleep apnea (OSA) is a common condition in morbidly obese patients, with the reported prevalence ranging from 12-78%. There is increasing recognition of the need to diagnose and treat/manage OSA both preoperatively and postoperatively. Nasal CPAP is the preferred treatment of OSA; however, weight loss is associated with a reduction in required pressures. We evaluated the CPAP pressure requirements in a group of patients undergoing rapid weight loss following Roux-en-Y gastric bypass . Methods: 15 patients who had been diagnosed with OSA before surgery were retrospectively evaluated. All patients had demonstrated compliance on home CPAP therapy, were minimally 3 months post-surgery and had follow-up reports that their CPAP was less effective. We obtained data on age, sex, weight, BMI, and apnea/hypopnea index (AHI). Optimal CPAP pressure was obtained initially through attended in-laboratory complex polysomnography. Follow-up CPAP pressure was obtained using an auto-titrating PAP device at home. These data were used to evaluate the pressure changes that accompanied weight loss. Results: This group of patients had lost an average of 44.5 ± 19.4 kg. Four patients had achieved their goal weight. Their starting CPAP pressures averaged 11 ± 3.0 cm H₂O, with a range of 7-18 cm H₂O. Follow-up CPAP pressures averaged 9 ± 2.7 cm H₂O, with a range of 4-12 cm H₂O, representing an overall reduction of 18%. The subgroup of patients who had achieved goal weight had a pressure reduction of 22% (9 ± 2.0 to 7 ± 1.0 cm H₂O). Conclusion: CPAP pressure requirements change considerably in bariatric surgery patients undergoing rapid weight loss. Auto-titrating PAP devices have promise for facilitating the management of CPAP therapy during this time. Consideration should also be given to the use of autotitrating PAP units as the treatment of choice in these patients.     

Factor V Leiden and Postoperative Deep Vein Thrombosis in Patients Undergoing Open Roux-en-Y Gastric Bypass Surgery

Background: Patients undergoing bariatric surgery are at risk for deep venous thrombosis (DVT) and fatal pulmonary embolus. In the presence of genetic hypercoagulable disorders, accepted methods of DVT prophylaxis utilizing sequential compression devices and subcutaneous unfractionated heparin may not be adequate to prevent DVT or fatal PE. Methods and Results: 3 morbidly obese patients are described who underwent open Roux-en-y gastric bypass and either had a previous diagnosis of Factor V Leiden or developed thrombosis in the presence of standard prophylaxis. Each was found to have the most common point mutation for Factor V Leiden, R506Q. All 3 patients had prophylactic inferior vena caval filters placed to prevent recurrent PE. Conclusion: The presence of venous thromboembolism either without known risk factors or in the presence of standard perioperative prophylaxis for DVT should warrant a hypercoagulable work-up. Inferior vena caval filter placement is indicated in the presence of a hypercoagulable disorder prior to surgical intervention in the morbidly obese population. The recent literature is reviewed.     

Laparoscopic Vertical Banded Gastroplasty: 5-year Results

Background:Vertical banded gastroplasty (VBG) has been a popular bariatric operation for the past 2 decades, and this operation has evolved into a laparoscopic procedure. However, reports of laparoscopic VBG (LVBG) from large series with longer results are limited. Methods: From October 1998 to May 2002, 612 consecutive patients underwent LVBG. Mean age was 30.1 years and mean BMI 43.0 kg/m². Laparoscopic Mason gastroplasty was performed. The change of BMI, obesity-related co-morbidities, and GI quality-of-life index (GIQLI) were studied. Results: The major and minor complication-rate was 1.14% and 4.58% respectively. The mortality-rate was 0.16%. Mean BMI fell from 43.1 kg/m² to 31.2, 31.3, 31.4, 32.2, and 32.8 kg/m² at 1, 2, 3, 4, and 5 years respectively, with 93% follow-up. Revision rate was 9.2%. GIQLI decreased from 113.0 to 106.6, 110.9, 111.9, 112.1, and 106.4 at 1, 2, 3, 4, and 5 years. Conclusion: LVBG is safe and effective in weight reduction. The GIQLI failed to improve postoperatively even with good resolution of obesity-related co-morbidities. In carefully selected patients with diligent postoperative follow-up, LVBG is a bariatric surgery option.