Late Gastric Prolapse with Pouch Necrosis after Laparoscopic Adjustable Gastric Banding

One of the most significant complications of the gastric banding procedure is gastric prolapse. However, pouch necrosis after gastric prolapse is an extremely rare complication. We present the case of a morbidly obese 41-year-old woman who had had a laparoscopic adjustable gastric banding procedure 3 years before. She developed a pouch necrosis after a late gastric prolapse. After failure of conservative treatment, a diagnostic laparoscopy was performed. This resulted in removal of the band and the diagnosis of pouch necrosis. A laparotomy was indicated and a sleeve gastrectomy was performed. A delay in the diagnosis of gastric prolapse can lead to major complications. Initial referral to a specialized center is necessary for proper care of this complication. Failure of conservative treatment mandates early operative intervention.     

Nutritional Behavior as a Predictor of Early Success after Vertical Gastroplasty

Background: Patients' nutritional habits are seldom taken in account in planning surgery for clinically severe obesity. Our proposed hypothesis is that the patient's nutritional behavior may influence the outcome of bariatric surgery. Methods: The impact of nutritional behavior on the postoperative weight-loss was evaluated before and after bariatric surgery. A 6-month prospective consecutive case study was carried out on patients undergoing a Silastic ring vertical gastroplasty (SRVG). Patients were interviewed and examined before and at 1, 3 and 6 months after surgery. Demographic and clinical data were collected from the patients' medical charts. Nutritional data collected from a self-filled questionnaire included information on hunger and satiety perception, nutritional behavior (intake, eating habits and maximum consistency of consumed food) and concomitant symptoms. Results: The sample included 69 patients: 56 were women (81%); average age was 32 years (range 18 50). Average preoperative BMI was 43.4 ± 5.3 kg/m² (range 35-58). 6 months after surgery, BMI was 30.3 ± 3.8 kg/m² (range 21-42). Weight loss forecast models showed a statistically significant role of factors related to: anthropometrical preoperative data, hunger perception, prevalence of oral mucosal sore, and nutritional behavior. Conclusion: The short nutrition outcomes after gastric restrictive surgery were looked at, with their impact on weight-loss success. The Eating Status concept should be part of a systematic profiling of morbidly obese patients for preoperative nutritional behavior and postoperative nutritional education, to achieve the best comprehensive treatment in regard to weight loss and quality of life.     

Laparoscopic Roux-en-Y Gastric Bypass in Patients with BMI <50: A Prospective Randomized Trial Comparing Short and Long Limb Lengths

Background: It has been shown that long limb gastric bypass in the super-obese (BMI >50) results in increased weight loss in comparison with conventional gastric bypass. The purpose of this study was to compare the effect of short and long limb lengths in patients with BM I<50. Methods: 48 patients with BMI <50 (46 females / 2 males, mean age 35±9.6 years) were prospectively randomized to either a short limb (biliopancreatic limb = 50 cm, alimentary limb = 100 cm) or long limb (biliopancreatic limb = 100 cm, alimentary limb = 150 cm) laparoscopic Roux-en-Y gastric bypass (LRYGBP). In all patients, a 25-mm EEA was used to fashion the gastrojejunostomy and the Roux limb was positioned in an antecolic, antegastric location. Limb lengths were precisely measured in all cases. Results: There was no difference in demographic data, preoperative BMI, presence of co-morbidities, or duration of surgery. The overall complication rate was not different between the 2 groups; however, the incidence of internal hernias was significantly higher in the long limb group (0 vs 4, P=0.029). The length of hospital stay was longer for the short limb group compared to the long limb group (3.1 vs 2.2 respectively, P=0.004). When comparing the short limb to the long limb patients, the BMI decreased equally in both groups at the following time intervals: preoperative (44.6 vs 44.9), 3 weeks (40.3 vs 40.9), 3 months (35.5 vs 35.2), 6 months (31.2 vs 31.8), and 12 months (27.7 vs 28.3). There were no significant nutritional deficiencies in either group. Conclusions: In patients with BMI <50 undergoing LRYGBP, increasing the length of the Roux limb does not improve weight loss and may lead to a higher incidence of internal hernias.     

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.     

Psychosocial Predictors of Success following Bariatric Surgery

Background: Bariatric surgery is the treatment of choice for morbid obesity, but it does not lead to equal results in every patient. In addition to surgery, a number of non-surgical and psychological factors may influence patients' ability to adjust to the postoperative condition. Understanding the relationship between potential predictive variables and success after bariatric surgery will enable better patient selection, and the development of interventions to improve outcome. Methods: A systematic literature search identified relevant variables, such as demography, preoperative weight, motivation, expectations, eating behavior, psychological functioning, personality, and psychiatric disorders, which may have predictive value for success after bariatric surgery. Results: Greater success following bariatric surgery appears to occur in patients who are young and female, and have a high self-esteem, good mental health, a satisfactory marriage, and high socio-economic status, who are self-critical and cope in a direct and active way, are not too obese, were obese before the age of 18, suffer from and are concerned about their obesity, have realistic expectations and undisturbed eating behaviors. Occasionally, these variables may have poor or no predictive value. Although reliable predictors are lacking, most treatment teams propose their own exclusion criteria. Conclusion: The existing literature about potential predictors of success after bariatric surgery is far from conclusive; it is still uncertain which factors can predict success. Even where psychosocial functioning does not predict outcome, it is important to identify patients' characteristics which may be linked to their prognosis and to provide necessary pre- and postoperative psychosocial interventions.     

Enoxaparin for Thromboprophylaxis in Morbidly Obese Patients Undergoing Bariatric Surgery: Findings of the Prophylaxis Against VTE Outcomes in Bariatric Surgery Patients Receiving Enoxaparin (PROBE) Study

Background: Obese patients undergoing bariatric surgery are at significant risk for venous thromboembolism (VTE). We performed a multicenter, retrospective survey to evaluate the safety and efficacy of enoxaparin for thromboprophylaxis in patients with morbid obesity undergoing primary bariatric surgery. Methods: From January to December 2002, 668 patients who underwent primary bariatric surgery at 5 centers were analyzed retrospectively. Baseline patient demographics, objectively diagnosed cases of VTE, and bleeding events were recorded. Patients received enoxaparin preoperatively (30 mg) or postoperatively (40 mg) every 12 or 24 hours or upon discharge (30 mg every 24 hours for 10 days). Results: Overall, there were 6 (0.9%) pulmonary embolisms (PE) and 1 (0.1%) occurrence of deep vein thrombosis (DVT); all but 1 occurred after the cessation of thromboprophylaxis. The highest incidence of VTE was at Center B, which did not administer perioperative thromboprophylaxis (1 DVT and 2 PEs). There were 6 (0.9%) severe bleeding complications: 3 at center D and 3 at center E. In Center B, 2 deaths were recorded (0.3%): 1 due to sepsis and 1 due to bleeding, with both occurring after thromboprophylaxis was discontinued. Conclusion: The administration of enoxaparin, in various dosing regimens, is safe for thromboprophylaxis in morbidly obese patients undergoing bariatric surgery. Fewer events occurred with perioperative prophylaxis initiated in the hospital. Because all thromboembolic events occurred after the cessation of thromboprophylaxis, extended thromboprophylaxis may be of value.     

Short-term Results of Laparoscopic Mini-Gastric Bypass

Background: The laparoscopic mini-gastric bypass (MGB) is a modification of Mason's loop gastric bypass, but with a long lesser curvature tube. With weight loss results similar to laparoscopic Roux-en-Y gastric bypass (LRYGBP), the MGB is a simpler operation with a low complication rate. Controversy exists concerning the efficacy and side-effects of this procedure. This report presents the technique of laparoscopic MGB and its results in 423 patients. Methods: From October 2001 to October 2004, 423 consecutive patients (87 males and 336 females) underwent laparoscopic MGB (LMGB) for morbid obesity. Mean age was 30.8 years, preoperative mean weight 120.3 kg and mean BMI 44.2 kg/m². Results: All procedures were completed laparoscopically. Mean operative time was 130.8 minutes, and mean hospital stay was 5.0 days. 18 minor early complications (4.3%) were encountered, and 7 major complications (1.7%) occurred. Marginal ulcers were noted in 34 patients (8.0%) during follow-up, and anemia was found in 41 patients (9.7%). Mean BMI decreased to 29.2 and 28.4 kg/m² at 1-year and 2-year follow-up, with mean excess weight loss 69.3% and 72.2%. The Gastrointestinal Quality of Life Index improved significantly 1 year after the operation. Conclusions: LMGB has a low complication and mortality rate. The learning curve is less steep than for LRYGBP, whereas the efficacy is similar.     

Effect on Gastric Emptying and Weight Reduction of Botulinum Toxin-A Injection into the Gastric Antral Layer: An Experimental Study in the Obese Rat Model

Background: We investigated the effects of Botox-A on weight loss and gastric emptying in an experimental obese rat model. Although there is evidence of weight loss in normal-weight rats after Botox-A injection, there are no studies indicating the effect of Botox-A injection on weight loss and gastric emptying time in obese rats. Methods: 37 female Wistar Albino rats were given high calorie diet for 90 days. They were separated into 3 groups. The first group (Botox group) consisted of 15 obese rats whose gastric antrum was injected with 20 U of Botulinum Toxin Type A. The second group (Saline group) consisted of 15 obese rats whose gastric antrum was injected with 20 U of saline. The third group (Control group) had no surgical intervention. Gastric scintigraphy was performed in the 3 groups pre- and postoperatively. Results: The saline group had a weight reduction in the early postoperative days but began to gain weight thereafter. The mean weight of the Botox group between the 16th and 28th days postoperatively was significantly lower than the mean weights of the control and the saline groups (P<0.05, P<0.001). The results of gastric emptying scintigraphy in all 3 groups at day 20 revealed significantly higher T1/2 values in the Botox-A group when compared to the results of the control and saline groups (P<0.001). Conclusion: Botox-A application to the gastric antrum in obese rats leads to weight loss by increasing the gastric emptying time.     

Liver Involvement in Obese Children (Ultrasonography and Liver Enzyme Levels at Diagnosis and During Follow-up in an Italian Population)

Our aim was to evaluate incidence and riskfactors of liver involvement in obese Italian childrenas assessed by both ultrasonographic and biochemicalparameters. In seventy-five consecutive obese children (age 9.5 ± 2.9 years, males/females41/34), serum levels of enzymes and ultrasonography ofthe liver were evaluated. Tests were repeated one,three, and six months after starting a moderatehypocaloric diet and an exercise program. Three obese childrenwho were found to have chronic viral hepatitis wereexcluded from the study. Thirty-eight of 72 (53%) obesechildren had an ultrasonographic image of bright liver consistent with liver steatosis. Thelatter was severe in nine children, moderate in 16, andmild in 13. Eighteen obese children (25%) had elevatedtransaminase levels. Bright liver andhypertransaminasemia were not due to any of the most common causesof liver disease. Both were rapidly responsive to lossof weight, confirming that liver involvement wassecondary to obesity and that steatosis orsteatohepatitis rather than fibrosis were involved. Obesityduration not more than three years (odds ratio = 4.77),a higher degree of obesity (odds ratio = 2.09), andhypertransaminasemia (odds ratio = 2.15) appeared asimportant predictive factors of liver involvement atultrasonography. Incidence of liver involvement assessedby means of ultrasonography is significantly higher thanthat revealed by measurement of serum liver enzymes. A short duration of obesity emerged as apotentially new risk factor of liver involvement in thepediatric obese population and needs to be confirmed infuture studies.     

Effect of Bariatric Surgery on Obstructive Sleep Apnea and Hypopnea Syndrome, Electrocardiogram, and Pulmonary Arterial Pressure

Background: We evaluated the impact of surgically-induced weight loss on Obstructive Sleep Apnea/Hypopnea Syndrome (OSAHS), electrocardiographic changes, pulmonary arterial pressure and daytime sleepiness in morbidly obese patients. Methods: 16 women and 13 men (n=29) underwent bariatric surgery in a 3-year period. The following tests were performed before and 1 year after surgery: nocturnal polysomnography, daytime Multiple Sleep Latency Test (MSLT), and echocardiogram. Results: Mean age was 37.9±11 years (range 20-56). Preoperative body mass index was 56.5±12.3 kg/m² and it was 39.2±8.5 kg/m² at 13.7±6.6 months follow-up. Performed surgical procedures included: vertical banded gastroplasty in 6, Roux-en-Y gastric bypass in 12, and Distal Roux-en-Y gastric bypass in 11. Weight loss induced by surgery eliminated OSAHS in 46% of obese patients with an important improvement in oxygen saturation. Neck, thorax, waist and hip circumferences decreased significantly after surgical intervention but only neck circumference correlated significantly with the apnea/hypopnea index (Spearman rho=0.63, P <0.0001). Electrocardiographic abnormalities were present in 9 patients (31%) before surgery (sinus arrhythmia, ventricular arrhythmias, and sinus arrest). The number of electrocardiographic abnormalities decreased after surgery but new abnormalities appeared in some patients. Systolic pulmonary arterial pressure significantly decreased in the group of patients in whom OSAHS disappeared after surgery. Daytime sleepiness persisted after surgery in most patients. Conclusion: Bariatric surgery effectively reduces respiratory disturbances during sleep and improves pulmonary hypertension. Electro cardiographic abnormalities change after surgery. Daytime sleepiness appeared not to be related to respiratory disturbances during sleep.