Banded Gastroplasty For Morbid Obesity Research Articles

Leber Hereditary Optic Neuropathy Associated with Malabsorption Syndrome After Bariatric Surgery

We report a patient who developed bilateral visual loss from Leber hereditary optic neuropathy (LHON) in conjunction with chronic malabsorption consequent to bariatric surgery. A 31-year-old man reported visual loss in his left eye and, 2 weeks later, in his right eye. His vision gradually worsened down to finger counting at a distance of 1 m, and he was admitted to the hospital for study. He had undergone vertical banded gastroplasty for morbid obesity 3 years earlier. He smoked 10 cigarettes/day and drank a few alcoholic drinks on weekends. Past ocular history was negative. Family history was remarkable for a maternal cousin with a history of unexplained poor vision since childhood. On our examination, visual acuity was 20/40 in the right eye and 20/200 in the left eye. There was a dense central scotoma in the visual field of the left eye and a pale optic disc in that eye. There was an afferent pupil defect on the left. No other ocular findings were detected, and results of the neurologic examination were unremarkable. Results of extensive hematologic, serologic, and cerebrospinal fluid studies were all normal or negative except for decreased serum levels of vitamin E at 3.4 μg/mL (normal range 5-20 μg/mL), borderline serum levels of vitamin B12 and folate (253 pg/mL and 3.6 ng/mL, respectively), and increased mean corpuscular volume at 101 fL. Results of CT and MRI of the brain and orbits were normal. Pattern-reversal visual evoked potentials revealed marked bilateral delay with P100 latencies of 130.8 ms from the right eye and 156.3 ms from the left eye. The patient received treatment with 1,000 mg/day methylprednisolone intravenously for 5 days, as well as oral vitamin B complex and vitamin E. There was no improvement in vision during his hospitalization. Genetic testing, performed at Public Foundation of Genomic Medicine (Santiago de Compostela, Spain), showed a homoplasmic mitochondrial DNA (mtDNA) mutation at position 11778A, confirming the clinical diagnosis of LHON. On a 10-month follow-up, clinical examinations showed no substantial changes. We have described a young man with a LHON mtDNA mutation and a history of moderate alcohol and tobacco abuse who developed subacute bilateral optic neuropathy in the setting of chronic malabsorption (multiple vitamin deficiency) induced by bariatric surgery. Epigenetic factors are reported to contribute to the clinical expression of LHON mtDNA mutations, including tobacco smoking, alcohol consumption, uncontrolled diabetes, ethambutol use, and antiretroviral therapy (1). There are similarities between the optic neuropathies of LHON, vitamin B1 deficiency, and vitamin B12 deficiency, suggesting that abnormalities of adenosine triphosphate levels might be the common underlying pathogenetic mechanism (2). In our patient, tobacco smoking and alcohol consumption may have contributed. Visual loss began after bariatric surgery, perhaps in the context of malabsorption. Asymptomatic 11778 mtDNA LHON carriers frequently show manifestations of optic nerve impairments in relation to environmental factors (3), just as mutations in the 12S rRNA gene of the mitochondrial genome increase susceptibility to the ototoxicity of aminoglycoside antibiotics (4). Three cases of LHON in subjects who also had low serum vitamin B12 levels at the time of symptom onset have recently been reported (5). Taken together, these observations suggest that optic neuropathy in patients carrying a primary LHON mtDNA mutation may be precipitated by vitamin deficiency. Patients who have undergone bariatric surgery show multiple biochemical abnormalities consistent with malabsorption, including low serum levels of vitamin B12, vitamin D, vitamin E, calcium, copper, or zinc. Some patients develop encephalopathy, optic neuropathy, posterolateral myelopathy, acute polyradiculoneuropathy, and polyneuropathy. Perhaps a positive family history of visual loss should prompt mtDNA investigations before bariatric surgery is considered. Diego Santos-García, MD, PhD Javier Abella, MD Section of Neurology Hospital A. Marcide Ferrol, Spain Begoña De Domingo, MD Service of Ophthalmology Hospital A. Marcide Ferrol, Spain Raúl de la Fuente-Fernández, MD Section of Neurology Hospital A. Marcide Ferrol, Spain [email protected]

Lumbosacral plexopathy associated with aortoiliac occlusive disease

Lumbosacral plexopathy associated with aortoiliac occlusive disease

Achalasia After Vertical Banded Gastroplasty for Morbid Obesity

Achalasia is an unusual motility disorder that can be seen in conjunction with obesity. The prevalence of achalasia is unknown in obese patients and when present, the clinical characteristics are atypical. We report a case of achalasia that was diagnosed 13 years after a vertical-banded gastroplasty was performed.

Incidence of incisional hernia following vertical banded gastroplasty.

Our aim was to determine which patient-related factors influence the incidence of incisional hernia after vertical banded gastroplasty for morbid obesity. We reviewed the medical records of 80 morbidly obese patients operated on between 1986 and 1993. All the operations were performed by only one surgeon, and the midline laparotomy was closed by means of continuous polyglactin 910 suture. Statistical analysis was performed using the Fisher exact test, and significance was assigned for values of P<0.05. Incidence of incisional hernia in: obese 24%, superobese 51% ( P=0.0165), men 40%, women 34% ( P=0.7671), age<50 33%, age>50 50% ( P=0.3137), nondiabetics 31%, diabetics 66% ( P=0.0610), no wound infection 34%, wound infection 37% ( P>0.9999), no anemia 31%, anemia 50% ( P=0.1675), no vomiting 39%, vomiting 32% ( P=0.6350). The only patient-related factor that significantly influences the incidence of incisional hernia in morbidly obese patients is body mass index.

Wernicke's Encephalopathy Following Gastroplasty for Morbid Obesity

The syndrome of Wernicke's encephalopathy consists of two of four features of (1) dietary deficiency; (2) oculomotor abnormality; (3) cerebellar dysfunction; and (4) confusion or mild memory impairment. Predisposing risk factors include alcoholism, hyperemesis gravidarum and prolonged intravenous feeding. A 35-year-old female developed refractory emesis, severe weight loss, and hypokalemia following banded gastroplasty for morbid obesity. Reversal of gastroplasty was performed four months following initial surgery. Following reversal, the patient developed confusion, ataxia, leg weakness and nystagmus. Examination of the patient demonstrated disorientation with confusion, vertical nystagmus worse on downgaze, diffuse weakness of the lower extremities, and bilateral dysmetria. Magnetic resonance imaging of the brain demonstrated symmetrical areas of increased T2 signal present bilaterally in the medial thalamic nuclei. The patient did not demonstrate any initial improvement with intravenous thiamine but improved over two months of follow-up. Wernicke's encephalopathy has been reported in the European literature as a complication of gastroplasty, with rare recognition of this clinical entity in the North American literature. This potential complication of gastroplasty may be preventable by nutritional intervention in subjects experiencing severe weight loss and emesis following surgery.

The Epidemic of Severe Obesity: The Value of Surgical Treatment

The Epidemic of Severe Obesity: The Value of Surgical Treatment

"No punch" technique of laparoscopic vertical banded gastroplasty for morbid obesity.

This report describes the technical details and an initial evaluation of laparoscopic vertical gastroplasty modified for morbid obesity. After a surgical experience in 150 patients with open vertical banded gastroplasty (Mason's procedure), it was decided to perform a modified banded vertical gastroplasty. Six patients were treated by this laparoscopic approach in 1997-1998. All patients were women with a mean age of 28 years (range 20-46). The mean body weight was 128 kg (range 105-146), and the mean BMI was 42.7 kg/m2 (range 35.6-53.0). Four or five 10- or 12-mm trocars were used. For all the dissection we used atraumatic ultracision (harmonic scalpel). In this procedure the technique of laparoscopic gastroplasty is performed without a circular gastric window. During the operation, 3 omental openings were made and the vertical staple-line was constructed by using a 30-mm 3-row linear stapler twice, establishing the gastric pouch. The outflow stoma was reinforced by a Gore-Tex band and calibrated to have an internal diameter of 10-15 mm. The band was sutured to itself. There were no deaths or complications. Operating time was 200 min (150-240). The nasogastric tube was removed at 1-2 days. The postoperative course was characterized by normal respiratory function and minimal pain in all cases. Patients were discharged 5-6 days after operation. Our technique excluded the circular gastric window (i.e., "no-punch") technique in the development of an effective and simple laparoscopic procedure to treat morbid obesity.

Gallstone formation after vertical banded gastroplasty for morbid obesity: Incidence, risk factors and role of gallbladder motility

Gallstone formation after vertical banded gastroplasty for morbid obesity: Incidence, risk factors and role of gallbladder motility

The place of upper gastrointestinal tract endoscopy before and after vertical banded gastroplasty for morbid obesity.

In industrialized countries, surgical gastroplasty is performed more and more frequently in patients with morbid obesity. The aims of this prospective study were to determine the incidence of upper gastrointestinal lesions in obese patients and to assess the place of digestive endoscopy in symptomatic patients after gastroplasty. A consecutive group of 159 obese patients were studied before and after vertical banded gastroplasty. In the preoperative evaluation, reflux esophagitis and gastroduodenal lesions were endoscopically observed in 31% and 37% of the patients, respectively. Interestingly, the majority of the obese patients with upper gastrointestinal lesions were asymptomatic. In the postoperative follow-up period, 55 of the 159 patients complained of upper gastrointestinal symptoms such as vomiting (72%), esophageal reflux (17%), and epigastric pain (3%). Stenosis of the outlet of the gastric pouch was described in 40 of the 55 symptomatic patients. Esophagitis was observed in 60% of these patients. Endoscopic dilation using Savary bougies or TTS balloon was successfully performed in all the patients with symptomatic stenosis of the gastric outlet. Food impaction was endoscopically removed in four patients. Thus, we recommend performing an upper gastrointestinal endoscopy in obese patients who are candidates for surgical gastroplasty because of the high incidence of upper gastrointestinal peptic lesions. Endoscopy is also helpful in patients with digestive disorders occurring after gastroplasty in order to define and to treat the lesions.

High potency parenteral B complex vitamin preparation is still available

EDITOR,—H Seehra and colleagues report that they successfully treated Wernicke's encephalopathy after vertical banded gastroplasty for morbid obesity by giving the patient intravenous Parentrovite.1 Unfortunately, this product was withdrawn (and subsequently discontinued worldwide) in …

Lesson of the Week: Wernicke's encephalopathy after vertical banded gastroplasty for morbid obesity

Thiamine deficiency is known to lead to certain neurological sequelae including Wernicke- Korsakoff encephalopathy. Signs attributable to this condition include ataxia, ophthalmoplegia, nystagmus, and mental confusion. Recognised predisposing conditions include alcoholism gastric carcinoma, pyloric obstruction, hyperemesis gravidarum, and prolonged intravenous feeding. We have recently encountered two cases of Wernicke's encephalopathy after vertical banded gastroplasty for morbid obesity . Other neurological sequelae are recognised after vertical banded gastroplasty, including Guillain-Barre syndrome, psychosis, and pseudoathetosis, but the causes are multifactorial.

Abdominoplasty following vertical banded gastroplasty for morbid obesity

We describe 15 patients who underwent abdominoplasty following vertical banded gastroplasty for morbid obesity between 1991 and 1994. Vertical banded gastroplasty was performed (by CMSR) on patients with a Body Mass Index greater than 39. Following this, the patients lost weight rapidly, leading to excess folds of skin and fat on the abdomen, arms and thighs, and were referred for plastic surgery when their weight had stabilised. After abdominoplasty, the Body Mass Indices of all the patients decreased to an acceptable range. Because vertical banded gastroplasty causes little long-term metabolic or nutritional disturbance, the abdominal skin could be undermined up to the costal margin and the umbilicus re-sited without major necrosis of the abdominal wall or umbilicus. All patients received prophylactic low dose heparin perioperatively until early ambulation. Prophylactic antibiotics were not used but there were no major wound infections. Patients were reviewed up to 12 months after abdominoplasty and were satisfied with the results. Abdominoplasty following vertical banded gastroplasty for morbid obesity safely provides acceptable cosmetic results.

Vertical banded gastroplasty for morbid obesity: weight loss at short and long-term follow up.

A standardized vertical banded gastroplasty (VBG) was carried out by the one surgeon on 60 consecutive morbidly obese patients. All patients were followed at 4 week intervals for 1.5 years. Long-term follow up was carried out at medians 5.7 and 9.6 years. All patients had significant weight loss at 1.5 years. However, at long-term follow up, despite an apparently intact gastric restrictive procedure, only 40% of patients had maintained their weight loss. Sixty per cent had regained significant weight and 31% had returned to or were above their pre-operative weight level.

Biochemical Changes after Vertical Banded Gastroplasty for Morbid Obesity

A prospective study of biochemical changes after vertical banded gastroplasty for morbid obesity, in 94 patients (10 males and 84 females, ages ranging from 18 to 59 years) has been carried out. Liver function tests and electrolyte estimations were performed preoperatively, during hospitalization for surgery, at 6 weeks and at 6 months postoperatively, and demonstrated no significant changes in liver function in these patients 6 months after surgery. The study concludes that there is no increase in the risk of liver damage or electrolyte disturbance after vertical gastroplasty, but that there may be subtle hepatic changes present as gall bladder disease developed in 18 patients postoperation (19%).

Radiological evaluation of the vertical banded gastroplasty for morbid obesity

Vertical banded gastroplasty (VBG) was performed in 70 morbidly obese patients between September 1988 and February 1991. All patients underwent a routine abdominal ultrasonographic (US) ctudy preoperatively, an upper gastrointestinal (GI) contrast study on the fifth day after VBG, and US and upper GI studies at 6, 12, 18 and 24 months postoperatively. The main abnormalities detected included staple-line distuption (22.85%), extragastric leak (2.85%), outlet obstruction (7.14%), gallstones (37.14%) and fatty liver (75.50 %). Asymptomatic cholelithiasis following VBG was detected by US in 25.8% of cases. Hepatic US follow-up showed the echographic pattern had returned to normal in 47.61% of cases. The 100% sensitivity and 100% specificity of gallstone detection at pre-VBG study in this series further confirms the role of US in the evaluation of cholithiasis, even in the morbidly abese. The 88.67% sensitivity and 100% specificity of fatty liver detection by US is similar to results from other studies. We suggest US and upper GI studies should be carried out routinely in morbidly obese patients not only for early detection of postsurgical complications but also to evaluate cholelithiasis and hepatic parenchyma following VBG.

Severe Reflux Esophagitis After Vertical Banded Gastroplasty for Treatment of Morbid Obesity

Herein we describe two patients with medically refractory, severe reflux esophagitis after vertical banded gastroplasty for morbid obesity. Neither patient had symptoms of reflux preoperatively. Both patients underwent conversion to a vertical Roux-en-Y gastric bypass, an operation that prevents acid and peptic reflux and maintains a weight-reducing anatomy. Symptoms of gastroesophageal reflux are common (they occur in approximately 38% of patients) after vertical banded gastroplasty has been performed. Patients with unusually severe reflux may require operative management.

Weight control after vertical banded gastroplasty for morbid obesity

Vertical banded gastroplasty is a common method of treating morbid obesity. Several physical, behavioral, economic, and psychologic factors are believed to affect its efficacy. In this study, 100 consecutive patients received a 4.5-cm circumference band, while a second 100 consecutive patients were given a 5.0-cm circumference band. One year after surgery, with a follow-up of 97.5%, neither the patient's stoma size nor their preoperative occupation, economic status, or mental health significantly affected the patient's weight loss, which averaged 27% of their original weight. Postoperative eating behavior, however, dramatically affected weight loss. Among the patients who lost less than 20% of their original weight, 25% drank large volumes of caloried liquids, while 75% ate large amounts of soft foods. Patients with banded gastroplasties must “use” their operation to lose weight.

Splenic Injury and Repair During Bariatric Surgical Procedures

Incidental splenectomy during exploratory laparotomy significantly increases morbidity and mortality. These rates, elevated in the morbidly obese, prompted a splenic preservation policy for any splenic injury during bariatric surgery. This review was needed to assess how this policy affected this population's intrinsically high perioperative risks. Six of 200 patients having primary or revisional vertical banded gastroplasty for morbid obesity or failure of previous bariatric surgery had splenic injury. In one case, splenectomy was necessary; in the other five, splenic repair was relatively easy and was not followed by problems related specifically to splenic surgery. Risks for splenic injury include previous operation, rigid retractors, adhesions in the left upper quadrant, and traction on adjacent viscera. We conclude that splenic injury during bariatric surgery should be repaired by the simplest hemostatic method(s). Splenectomy should be reserved for the irreparably injured organ or when instability of the patient's condition demands promptness.

Manometric study of vertical banded gastroplasty for morbid obesity.

Morbidly obese patients undergoing vertical banded gastroplasty were studied preoperatively and/or postoperatively to characterize its manometric pattern. The esophageal manometry using station pull through technique involved 14 preoperative patients with a mean age of 28 +/- 7 years who were a obesity index of 220 +/- 32% and 14 postoperative patients with a mean age of 30 +/- 7 years who were a obesity index of 158 +/- 23%. Preoperative lower esophageal sphincter (LES) pressure using gastric base line as O was 16.1 +/- 8.5 cmH2O and a LES length of 3.4 +/- 0.9 cm. Postoperatively, the vertical banded gastroplasty channel had a pressure of 17.7 +/- 7.1 cmH2O and a length of 8.2 +/- 1.7 cm which was higher than gastric base line. No difference was seen between preoperative LES pressure and postoperative channel pressure, however postoperative channel length was significantly (p less than 0.01) larger than preoperative LES length. We concluded that vertical banded gastroplasty for morbid obesity created a longer high pressure zone in accordance with channel which would inhibit reflux of gastric juice.

A Randomized Prospective Trial of Gastric Bypass Versus Vertical Banded Gastroplasty for Morbid Obesity and their Effects on Sweets Versus Non-Sweets Eaters

Vertical banded gastroplasty (VBGP) was compared with Roux-en-Y gastric bypass (RYGBP) in a randomized prospective trial that included preoperative dietary separation of "sweets eaters" versus "non-sweets eaters." Randomization was stopped at 9 months after 20 patients had undergone each procedure because a greater weight loss (p less than 0.05) was noted after RYGBP than VBGP. This difference became more significant (p less than 0.001) at each 3-month interval through 3 years, when patients who had VBGPs had lost 37 +/- 20% of excess weight compared with 64 +/- 19% for patients who had RYGBPs. The members of the groups were comparable with regard to age, sex, eating habits, morbidity rates before surgery, ideal body weight, and weight before surgery. Although there was no significant difference between the loss of excess weight in "sweets eaters" (69 +/- 17%) or "non-sweets eaters" (67 +/- 17%) after RYGBP at 1 year, "sweets eaters" who had VBGPs lost significantly less excess weight (36 +/- 13%) than did "non-sweets eaters" who had VBGPs (57 +/- 18%), p less than 0.02, or "sweets eaters" who had RYGBPs, p less than 0.0001. No significant differences were noted for electrolytes, renal or liver function tests, and most vitamins between patients who had VBGPs and RYGBPs; however, patients who had RYGBPs had lower (p less than 0.05) serum vitamin B12 levels (286 +/- 149 pg/dl) than did patients who had VBGPs (461 +/- 226 pg/dl) at 2 years. By 3 years, the vitamin B12 levels were equal in members of the two groups. Five patients who had RYGBPs required endoscopic stomal dilatation for stomal stenosis and one had a marginal ulcer develop, which responded to cimetidine. RYGBP was clearly superior to VBGP for "sweets eaters," probably because of the development of dumping syndrome symptoms. However, RYGBP was associated with a larger number of correctable problems. Thus, it is important to evaluate a patient's eating habits before surgery for morbid obesity; "non-sweets eaters" probably should be treated with VBGP and "sweets eaters" with RYGBP.