Excess Body Weight Loss Research Articles

Single-port Roux-en-Y gastric bypass: toward a less invasive procedure with the same surgical results and a better cosmesis

The current tendency to use increasingly less aggressive procedures has facilitated the development of new minimally invasive techniques. In this context, single-port (SP) access procedures can become an alternative to the conventional laparoscopic approach. A total of 22 morbidly obese patients were submitted to pure SP Roux-en-Y gastric bypass without additional ports. Selection for this approach was based on distance from the xiphoid to the umbilicus less than 28 cm, body mass index (BMI) lower than 50 kg/m(2), and preferably peripheral obesity. Access to the cavity was obtained through a single transverse, transumbilical incision, with placement of a SILS Port device. The mean age of the patients was 41 ± 8.98 years, and 95 % of the patients were women. The mean BMI of the series was 42.68 ± 2.28 kg/m(2), and the mean body weight was 111.34 ± 10.66 kg. Surgery was performed successfully in all cases through a transumbilical incision with a mean length of 26.68 ± 5.27 mm. The mean surgical time was 114.05 ± 21 min, and the mean hospital stay was 3.27 ± 1.01 days. No intraoperative or immediate postoperative deaths or complications occurred. The median postoperative BMI during a mean follow-up period of 12 months was 28 kg/m(2) (range, 18-35 kg/m(2)). The median weight loss was 39 kg, and the percentage loss of excess body weight was 86 %. In relation to improvement of the comorbidities, two of the three patients with arterial hypertension showed normalization of their blood pressure values. Likewise, the blood glucose levels were corrected in two of the three diabetic patients, as well as in the patient with altered fasting blood glucose. Single-port Roux-en-Y gastric bypass surgery seems to be a safe, viable, and reproducible technique, but randomized studies involving larger patient series and longer follow-up periods are needed to compare the SP access and the multiple-port laparoscopic approach.

Greater Short-Term Weight Loss in Women 20–45 versus 55–65 Years of Age Following Bariatric Surgery

Whether and how sex and age affect bariatric-surgery outcome is poorly understood. Estrogens regulate body composition in women and animals, and increase weight loss in a rodent model of gastric bypass, suggesting that premenopausal women may lose more weight following bariatric surgery. One thousand three hundred fifty-six female gastric-bypass or gastric-banding patients were retrospectively grouped as 20-45years old (presumptively premenopausal; n = 1,199) and 55-65years old (presumptively postmenopausal; n = 157). Mixed-model ANCOVA followed by Bonferroni-corrected t tests were used to categorically test the effect of age on percent excess body weight loss (%EBWL) at 1 and 2years post-surgery, controlling for preoperative EBW and surgery type. Age effects were also tested dimensionally in all women and in 289 male patients. Twenty- to forty-five-year-old women showed greater %EBWL 1 and 2years post-surgery than 55-65-year-old women (p's < 0.0005). No age effect was detected in 20-25- vs. 30-35-, 30-35- vs. 40-45-, or 20-25- vs. 40-45-year-old women (p's > 0.2) This age effect was detected only after gastric banding, with 20-45-year-old women losing ∼7kg more than 55-65-year-old women after 2years. Dimensional analysis confirmed a significant inverse effect of age on bariatric surgery outcome in women, but did not detect any effect in men. Results indicate that 55-65-year-old women lose less weight than 20-45-year-old women in the initial 2years after bariatric surgery, especially gastric banding; this may be mediated by age- or menopause-associated changes in physical activity, energy expenditure, or energy intake.

The Comparative Effectiveness of Sleeve Gastrectomy, Gastric Bypass, and Adjustable Gastric Banding Procedures for the Treatment of Morbid Obesity

To evaluate the comparative effectiveness of sleeve gastrectomy (SG), laparoscopic gastric bypass (RYGB), and laparoscopic adjustable gastric banding (LAGB) procedures. Citing limitations of published studies, payers have been reluctant to provide routine coverage for SG for the treatment of morbid obesity. Using data from an externally audited, statewide clinical registry, we matched 2949 SG patients with equal numbers of RYGB and LAGB patients on 23 baseline characteristics. Outcomes assessed included complications occurring within 30 days, and weight loss, quality of life, and comorbidity remission at 1, 2, and 3 years after bariatric surgery. Matching resulted in cohorts of SG, RYGB, and LAGB patients that were well balanced on baseline characteristics. Overall complication rates among patients undergoing SG (6.3%) were significantly lower than for RYGB (10.0%, P < 0.0001) but higher than for LAGB (2.4%, P < 0.0001). Serious complication rates were similar for SG (2.4%) and RYGB (2.5%, P = 0.736) but higher than for LAGB (1.0%, P < 0.0001). Excess body weight loss at 1 year was 13% lower for SG (60%) than for RYGB (69%, P < 0.0001), but was 77% higher for SG than for LAGB (34%, P < 0.0001). SG was similarly closer to RYGB than LAGB with regard to remission of obesity-related comorbidities. With better weight loss than LAGB and lower complication rates than RYGB, SG is a reasonable choice for the treatment of morbid obesity and should be covered by both public and private payers.

Adjustable Gastric Band as Surgical Treatment for Morbid Obesity. Are Worldwide Results Reproducible in Spain?

IntroductionAdjustable gastric banding is a surgical technique used all over the world for the treatment of morbid obesity. In Spain, the number of patients treated with adjustable gastric banding is far lower than the average worldwide average. A number of reasons have been put forward to explain this difference. Materials and methodsA program of bariatric surgery by means of implantation of an adjustable gastric banding was started in 2001, together with a dedicated follow-up protocol in order to prevent complications and improve results. ResultsA total of 132 patients were operated on between 2001 and 2011. The mean age of the 102 female and 30 male patients was 39 years, and the mean body mass index was 43. Follow-up was longer than 5 years in 61 patients, while the mean follow-up in the rest was 44.4 months. There was no mortality or severe morbidity. Eight patients (6.06%) underwent reoperation, 3 of them for complications related to the reservoir, 4 for slipping of the band, and one for erosion. One slipped band was removed, and a new one (of the Lap Band type) was inserted. Three slipping bands were converted to other techniques. The percentage excessive body weight loss was maintained in 54.8% of the patients followed-up for longer than 5 years. ConclusionsThe results of our series are comparable to those reported in the literature and show that, provided that a close follow-up, like that performed by most groups, is implemented, adjustable gastric banding can also be a safe and effective bariatric surgery technique in our country.

Genome-wide Association of Single-Nucleotide Polymorphisms With Weight Loss Outcomes After Roux-en-Y Gastric Bypass Surgery

Roux-en-Y gastric bypass (RYGB) is among the most effective treatments for extreme obesity and obesity-related complications. However, despite its potential efficacy, many patients do not achieve and/or maintain sufficient weight loss. Our objective was to identify genetic factors underlying the variability in weight loss outcomes after RYGB surgery. We conducted a genome-wide association study using a 2-stage phenotypic extreme study design. Patients were recruited from a comprehensive weight loss program at an integrated health system. Eighty-six obese (body mass index >35 kg/m(2)) patients who had the least percent excess body weight loss (%EBWL) and 89 patients who had the most %EBWL at 2 years after surgery were genotyped using Affymetrix version 6.0 single-nucleotide polymorphism (SNP) arrays. A second group from the same cohort consisting of 164 patients in the lower quartile of %EBWL and 169 from the upper quartile were selected for evaluation of candidate regions using custom SNP arrays. We performed RYGB surgery. We assessed %EBWL at 2 years after RYGB and SNPs. We identified 111 SNPs in the first-stage analysis whose frequencies were significantly different between 2 phenotypic extremes of weight loss (allelic χ(2) test P < .0001). Linear regression of %EBWL at 2 years after surgery revealed 17 SNPs that approach P < .05 in the validation stage and cluster in or near several genes with potential biological relevance including PKHD1, HTR1A, NMBR, and IGF1R. This is the first genome-wide association study of weight loss response to RYGB. Variation in weight loss outcomes after RYGB may be influenced by several common genetic variants.

Gastric pouch reduction using StomaphyX™ in post Roux-en-Y gastric bypass patients does not result in sustained weight loss: a retrospective analysis

Gastric bypass is the "gold standard" procedure of bariatric surgery. However, 20.4-34.9% of these patients may fail to achieve or maintain the weight loss on long-term follow-up and may require additional procedures. StomaphyX has been promoted for weight reduction in such patients. To study whether endoluminal reduction of gastric pouch and stoma using StomaphyX results in sustained weight loss in patients who regain weight after gastric bypass. Retrospective chart review was performed on 59 postgastric bypass patients who underwent revision of gastric pouch using StomaphyX from 2007 to 2008. Postprocedure weight at 1 week, 1 month, and 6 months follow-up as well as weight at the time of the review was recorded for each patient. Average weight loss and excess body weight loss (EBWL) were 2.6 ± 2.3 kg and 7.3 ± 7.1% (n = 42) at 1 week, 3.7 ± 2.9 kg and 11.6 ± 12.1% (n = 31) at 1 month, and 3.8 ± 4.5 kg and 11.5 ± 17.9% (n = 10) at 6 months respectively. At the time of review, the average follow-up was 41 months, average weight loss was 1.7 ± 9.7 kg, and EBWL was 4.3 ± 29.8% (n = 53). Endoscopy in 12 patients at average 18 months follow-up showed no sustained reduction in pouch and stoma size. StomaphyX results in weight loss that is not sustained on long-term follow-up. Pouch and stoma tend to regain their preprocedure size on follow-up. StomaphyX cannot be recommended as a weight loss strategy in postgastric bypass patients who regain weight.

La banda gástrica ajustable como tratamiento de la obesidad mórbida: ¿son reproducibles los resultados mundiales en España? Análisis de 132 pacientes intervenidos en los últimos 10 años

IntroductionAdjustable gastric banding is a surgical technique used all over the world for the treatment of morbid obesity. In Spain, the number of patients treated with adjustable gastric banding is far lower than the average worldwide average. A number of reasons have been put forward to explain this difference. Material and methodsA program of bariatric surgery by means of implantation of an adjustable gastric banding was started in 2001, together with a dedicated follow-up protocol in order to prevent complications and improve results. ResultsA total of 132 patients were operated on between 2001 and 2011. The mean age of the 102 female and 30 male patients was 39 years, and the mean body mass index was 43. Follow-up was longer than 5 years in 61 patients, while the mean follow-up in the rest was 44.4 months. There was no mortality or severe morbidity. Eight patients (6.06%) underwent reoperation, 3 of them for complications related to the reservoir, 4 for slipping of the band, and one for erosion. One slipped band was removed, and a new one (of the Lap Band type) was inserted. Three slipping bands were converted to other techniques. The percentage excessive body weight loss was maintained in 54.8% of the patients followed-up for longer than 5 years. ConclusionsThe results of our series are comparable to those reported in the literature and show that, provided that a close follow-up, like that performed by most groups, is implemented, adjustable gastric banding can also be a safe and effective bariatric surgery technique in our country.

Flipping the Switch

Bariatric surgery is an increasingly popular approach for effecting significant weight reduction in obese patients with comorbidities, including hepatic steatosis. Here we report a novel case of advanced nonalcoholic steatohepatitis (NASH) fibrosis with portal hypertension after duodenal switch bariatric surgery, resolving histopathologically with partial reversal of the malabsorptive procedure.1 BPD/DS, biliopancreatic diversion with duodenal switch; CPT, Childs-Pugh-Turcotte; DM, diabetes mellitus; JIB, jejunoileal bypass; MELD, model for endstage liver disease; NASH, nonalcoholic steatohepatitis. A 50-year-old male with a history of morbid obesity and no alcohol prior to presentation presented to the Hepatology Clinic with cirrhosis secondary to NASH. Three years prior, the patient underwent biliopancreatic diversion with duodenal switch (BPD/DS). Two years postsurgery he had lost 188 pounds with resolution of hypertension and diabetes mellitus (DM). At presentation the patient was noted to have extensive bridging fibrosis on percutaneous liver biopsy with trichrome staining (Fig. 1) complicated by portal hypertensive ascites and mild hepatic encephalopathy. Computed tomography (CT) of the abdomen noted diminished size with nodular contour of the liver and moderate ascites. His initial model for endstage liver disease (MELD) was 19 (international normalized ratio [INR] 1.50, total bilirubin 1.9 mg/dL, creatinine 1.8 mg/dL; weight = 193 lbs; body mass index [BMI] = 29.3; albumin = 3.4 gm/dL [after albumin infusions]) and he was Childs-Pugh-Turcotte (CPT) Class B. After supportive care including albumin and titration of diuretics his MELD declined to 15 (INR 1.50, total bilirubin 1.5 mg/dL, Cr 1.3 mg/dL). Successful transjugular intrahepatic portosystemic shunt (TIPS) placement for refractory ascites was then performed. Unfortunately, he continued to do poorly despite diuresis and nutritional support (1 month post-TIPS weight = 176 lbs; BMI = 26.8; albumin = 2.4 gm/dL). Liver Biopsy after partial reversal of duodenal switch demonstrating near total resolution of steatohepatitis and fibrosis. (Trichrome) At a MELD of 11 (INR 1.40, total bilirubin 1.1 mg/dL, creatinine 1.1 mg/dL) and CPT class B (albumin 2.0 mg/dL) the BPD/DS was partially reversed, due to protein malnutrition (weight = 149 lbs; BMI = 22.7; albumin = 2.0 gm/dL). By way of laparoscopy with conversion to open procedure, a jejunojejunostomy was created with the duodenal switch limb. A side-to-side anastomosis of the biliopancreatic limb and the alimentary limb was made at least 100 cm proximal to origination of the existing 50-cm common channel. Six months after partial reversal his ascites resolved and his MELD declined to 6 (weight = 178 lbs; BMI = 27.1; albumin = 3.6 gm/dL [with no albumin infusion support]). Open liver biopsy during ventral hernia repair with trichrome staining 6 months post-reversal of BPD/DS demonstrated mild portal inflammation with mild to moderate portal fibrosis, mirroring an overall clinical improvement (Fig. 2). An abdominal ultrasound 9 months after the improved liver biopsy noted the liver to be normal in size with increased echogenicity. Liver biopsy before duodenal switch reversal demonstrating steatohepatitis and advanced fibrosis. (Trichrome) This is a unique case of resolution of decompensated cirrhosis with histologic regression of fibrosis following partial reversal BPD/DS. BPD/DS is a restrictive/malabsorptive surgery involving a pylorus-sparing vertical sleeve gastrectomy and creation of a Roux limb and duodenoileostomy with a short common channel. BPD/DS is advocated for patients with very severe obesity (BMI ≥50 gm/m2), and has been associated with improved weight loss against historical controls.2 As with other bariatric procedures, BPD/DS improves obesity comorbidities, such as hypertension, dyslipidemia, and DM.3 Complications are well documented after BPD/DS. In general, bariatric surgery complications are proportional to the amount of excess body weight loss (EBWL), with BPD-DS being the greatest (38%).4 Adverse events include anastomotic leak/stenosis, bleeding, nutritional deficits, wound complications, and hepatic steatosis. An earlier bariatric surgery, the jejunoileal bypass (JIB), was also a popular procedure for its profound weight loss. However, it is no longer used today due to high morbidity and mortality. With JIB, up to 40% of patients developed hepatic abnormalities that could lead to cirrhosis and often persisted after surgical reversal.5 In this case, our patient underwent bariatric surgery with significant EBWL and diminished BMI but suffered intolerable hepatic dysfunction. After partial surgical reversal, both clinical and histologic improvement occurred. There have been previous reports noting hepatic dysfunction after duodenal switch; however, we found no documented histologic and clinical improvement after reversal.6

A model case of a positive outcome in super-super obesity.

For an increasing number of obese patients, bariatric surgery is considered as the treatment of choice after the failure of conventional strategies. While numerous studies on bariatric surgery have shown substantial health benefits, there is a broad inter-individual variation in the long-term outcome, which is insufficiently understood. Here we show a favourable long-term outcome following multidisciplinary care in a super-super-obese patient. The patient suffered from numerous typically obesity-associated comorbidities and limitations. He underwent multidisciplinary care including two-step bariatric intervention. Endoscopic intragastric balloon positioning was followed by gastric sleeve surgery without Roux-en-Y gastric bypass. His body weight dropped from 260 kg (body mass index [BMI] 79.4 kg m(-2) ) to 85 kg (BMI 25.9 kg m(-2) ) within 16 months and continued to be stable at 90 kg (BMI 27.8 kg m(-2) ) at the end of the follow-up period of 48 months. The loss of excess body weight was associated with the remission of numerous obesity-related comorbidities and with a concomitant pronounced increase in the quality of life and in the socioeconomic status. Eventually, the patient was able to lead a normal life with a decreased risk of long-term complications. We attribute the positive long-term outcome to the following potential determinants: individualized bariatric surgery, multidisciplinary care, the patient's long-term compliance, adequate adherence to the aftercare, physical exercise after surgery, family support, the cooperation of the primary care physician and the financial coverage by the health insurance. Some of these factors remain to be evaluated as predictors of a favourable long-term outcome in prospective trials.

Weight loss and ethnicity: A cohort study of the effects induced by a very low calorie diet

Background: We aimed to determine whether British Asians of Indian or Pakistani descent differed in their baseline characteristics and in response to a 12 week very low calorie diet (VLCD). We then assessed if changes in weight and waist circumference in response to a VLCD differs between Asians and Caucasians. Methods: Weight loss was achieved using a nutritionally complete (energy deficient), very-low-calorie diet (VLCD) with an average daily intake of 550kcal (50g protein,50g carbohydrate, mean 17g fats and ≥100% recommended daily allowances (RDA) for key vitamins and minerals), alongside a unique behaviour change programme (LighterLife “LL). Data from Asians recruited onto LL total in 2009/2010 for whom 12 week weight change information were available were analysed. Waist circumference data were available for a subset of Asians. These were age, body mass index, and gender matched to a Caucasian population and compared by independent t-test. Results: No differences were observed between the Indian and Pakistani group for baseline measurements or weight change at 12 weeks. Caucasians had a greater percent excess body weight loss (%EBWL) than Asians at 12 weeks (72.4 ± 22.1 vs 48.9 ± 18.0, p

Outcome Analysis of Early Laparoscopic Sleeve Gastrectomy Experience

Laparoscopic vertical sleeve gastrectomy (LSG) was initially performed as the first stage of biliopancreatic diversion with duodenal switch in the super-obese population. In the past few years, however, LSG has been performed as a definitive procedure because of its promising early and midterm results. In this study we describe our initial experience and outcomes with LSG as a potential independent bariatric operation. A prospectively maintained database including all patients between 2008 and 2011 was reviewed. A total of 100 initial consecutive patients (69 women and 31 men) were included, with a mean age of 50 years (range, 19 -79 years) and body mass index of 49 kg/m(2) (range, 36.6 -70.3 kg/m(2)). The mean operative time was 106 minutes (range, 58 -212 minutes) with a 2% conversion rate. Thirty-day perioperative complications included port-site hemorrhage (1.0%) and the inability to tolerate oral intake resulting in dehydration (3%). The reoperation rate was 2%, and the mean length of stay was 3.1 days (range, 2-12 days). In one patient with a prolonged hospital stay, an acute cholecystitis developed, and prosthetic heart valve complications developed in another patient. The mean excess body weight loss was 18%, 31.7%, 45%, 52%, 58.4%, and 64% at 1, 3, 6, 9, 12, and 18 months postoperatively, respectively. No deaths occurred in this series. Satisfactory outcomes and low complication rates were observed after LSG. Our findings suggest that LSG is safe and effective to serve as a definitive bariatric procedure.

Treatment of super obesity by laparoscopic Roux-en-Y gastric bypass: experience of 42 cases

To investigate the feasibility and efficacy of laparoscopic Roux-en-Y gastric bypass(LRYGB) for super obesity(BMI≥50 kg/m(2)). Clinical data of 42 patients undergoing LRYGB in the First Affiliated Hospital of Jinan University between 2004 and 2008 were analyzed retrospectively. All the LRYGB procedures were successfully performed with no conversion to open surgery. Average operation time was 145.1 minutes, volume of blood loss during the surgery was 25.0 ml, and length of postoperative hospital stay was 9.9 days. The cases were followed up for 1 month to 30 months. Body weight and BMI decreased significantly 1 month after the operation and reached a minimum level after 2 years then became stable while excess body weight loss rate(EWL) increased(P<0.05). All the obese-related symptoms were relieved significantly. Four cases(9.5%) showed complications during perioperative period including 1 case of respiratory failure, 2 cases of gastrojejunal anastomotic bleeding, 1 case of umbilical wound infection, and 11 developed long-term complications. All of them were cured by conservative treatment. Treatment of super obesity by LRYGB is feasible with significant short-term results. But due to the difficulty of the operation and postoperative complications, comprehensive treatment from experienced bariatric surgical team is needed. The long-term outcome needs for further observation.

Sleeve gastrectomy and Roux-en-Y gastric bypass exhibit differential effects on food preferences, nutrient absorption and energy expenditure in obese rats

All available treatments directed towards obesity and obesity-related complications are associated with suboptimal effectiveness/invasiveness ratios. Pharmacological, behavioral and lifestyle modification treatments are the least invasive, but also the least effective options, leading to modest weight loss that is difficult to maintain long-term. Gastrointestinal weight loss surgery (GIWLS) is the most effective, leading to >60-70% of excess body weight loss, but also the most invasive treatment available. Sleeve gastrectomy (SGx) and Roux-en-Y gastric bypass (RYGB) are the two most commonly performed GIWLS procedures. The fundamental anatomic difference between SGx and RYGB is that in the former procedure, only the anatomy of the stomach is altered, without surgical reconfiguration of the intestine. Therefore, comparing these two operations provides a unique opportunity to study the ways that different parts of the gastrointestinal (GI) tract contribute to the regulation of physiological processes, such as the regulation of body weight, food intake and metabolism. To explore the physiologic mechanisms of the two procedures, we used rodent models of SGx and RYGB to study the effects of these procedures on body weight, food intake and metabolic function. Both SGx and RYGB induced a significant weight loss that was sustained over the entire study period. SGx-induced weight loss was slightly lower compared with that observed after RYGB. SGx-induced weight loss primarily resulted from a substantial decrease in food intake and a small increase in locomotor activity. In contrast, rats that underwent RYGB exhibited a substantial increase in non-activity-related (resting) energy expenditure and a modest decrease in nutrient absorption. Additionally, while SGx-treated animals retained their preoperative food preferences, RYGB-treated rats experienced a significant alteration in their food preferences. These results indicate a fundamental difference in the mechanisms of weight loss between SGx and RYGB, suggesting that the manipulation of different parts of the GI tract may lead to different physiologic effects. Understanding the differences in the physiologic mechanisms of action of these effective treatment options could help us develop less invasive new treatments against obesity and obesity-related complications.

Bariatric surgery to treat type 2 diabetes

To critically discuss the strengths and shortcomings of recent progress achieved with bariatric surgery in patients with type 2 diabetes mellitus (T2DM), focussing on efficacy aspects (remission of diabetes and cardiovascular comorbidities). Despite an increasing armamentarium of pharmacotherapeutics to overcome several challenges, only 10% of T2DM patients achieve a composite goal of HbA1c, blood pressure and lipids. Bariatric surgery has emerged as a solution to these challenges in morbid obesity. Whether the same advantages can be translated into T2DM remains a matter of debate, certainly regarding safety, durability of diabetes recovery and long-term outcome. Bariatric surgery in T2DM patients with a BMI of at least 35 kg/m(2) has been shown to result in a 56% excess body weight loss, resolution of hypertension in 62%, amelioration of dyslipidaemia in greater than 70% and diabetes remission in 57-95%, depending on the type of surgery and the definition of diabetes resolution. These impressive results, and the fact that diabetes recovery often occurs before prominent weight loss is evident, have urged bariatric surgeons to consider surgical procedures as a valuable approach for diabetes control and diabetes remission in patients with a BMI ranging between 30 and 35 kg/m(2). Bariatric surgery is emerging as a valid option to treat T2DM, improving glycaemia and cardiovascular risk factors. However, there needs to be an agreed definition of resolution of diabetes in future studies and long-term efficacy is to be proven. For now, the challenge is to determine how to offer bariatric surgery in a responsible fashion.

Analysis of Obesity-Related Outcomes and Bariatric Failure Rates With the Duodenal Switch vs Gastric Bypass for Morbid Obesity

To compare the outcomes of a large cohort undergoing biliopancreatic diversion/duodenal switch (DS) vs gastric bypass (GB). Retrospective review of the Bariatric Outcomes Longitudinal Database from 2007 to 2010. All inpatient and outpatient follow-up data were analyzed. Multicenter database. Patients undergoing primary DS were compared with a concurrent cohort undergoing GB. The main outcome measures were (1) weight loss; (2) control of comorbidities including diabetes mellitus, hypertension, and sleep apnea; and (3) failure to achieve at least 50% excess body weight loss. One thousand five hundred forty-five patients underwent DS and 77 406 underwent GB, with a mean preoperative body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 52 and 48, respectively (P < .01). The DS was associated with longer operative times, greater blood loss, and longer lengths of hospital stay (all P < .05). Early reoperation rates were higher in the DS group (3.3% vs 1.5%). Percentage of change in BMI was significantly greater in the DS group at all follow-up intervals (P < .05). Subgroup analysis of the superobese population (BMI >50) revealed significantly greater percentage of excess body weight loss in the DS group at 2 years (79% vs 67%; P < .01). Comorbidity control of diabetes, hypertension, and sleep apnea were all superior with the DS (all P < .05). The risk of weight loss failure was significantly reduced with DS vs GB for all patients, with a greater reduction in the BMI more than 50 subgroup. The DS is a less commonly used bariatric operation, with higher early risks compared with GB. However, the DS achieved better weight and comorbidity control, with even more pronounced benefits among the superobese.

PP239-MON IS THERE A POSITIVE INFLUENCE OF THE AMINOACID COMPOUND CONTAINING ARGININE, β-HYDROXY-β-METHYLBUTYRATE AND GLUTAMINE ON WOUND HEALING?

Body Mass index for RYBP patients before surgery was 47.3±8.2 kg/m2, and after surgery 31.3±5 kg/m2. All patients had a % of excessive body weight loss >50%. RYGBP patients and non-obese healthy control subjects had significantly different citrulline (25.5±4.3 vs. 33.0±7.5 umol/L respectively; p < 0.01) and arginine (56.0±12.2 vs. 71.2±14.9mg/dL; p < 0.05) plasma levels. Participants had normal creatinine values (0.7 1.4mg/dL for men and 0.6 1.2mg/dL for women). Conclusion: Following Roux-en-y gastric bypass, the decrease in enterocyte mass is illustrated by a citrullinemia lower than normal, which in turn likely explains hypoargininemia. The clinical significance (e.g. in term of immune and healing functions) of the latter should be explored as well as the interest of supplementation.

Robotically-assisted laparoscopic biliopancreatic diversion with duodenal switch: the utility of the robotic system in bariatric surgery.

Biliopancreatic diversion with duodenal switch (BPD/DS) is considered the most effective surgical option for morbidly obese patients. Several techniques have been described: open, laparoscopic, and the combination of open and laparoscopic. Only a few centers in the world perform robotically-assisted laparoscopic BPD/DS and the published literature is limited. We describe our experience using this technique as a safe alternative for treatment of morbid obesity. A review of a prospectively maintained database from 2008 to 2011 was conducted. A total of 107 consecutive patients (F:M=83:24) were included in this series. Average age was 44.76years (range 20-67), body mass index 49.97 kg/m(2) (range 37-70), and the number of preoperative comorbidities was 6.24 (range 3-11). The mean operative time for a typical BPD/DS with or without an appendectomy was 264min (range 192-413), which increased to 298min (range 210-463) when lysis of adhesion or additional procedures were performed. All study cases were completed using a minimally invasive approach. There were no intraoperative or 30-day major postoperative complications. Two patients returned to the operating room: one for endoscopic release of an inadvertently-sutured nasogastric tube during creation of the duodeno-ileal anastomosis and another patient for a port-site infection. Minor postoperative complications included carpal tunnel syndrome exacerbation (n=1), which did not require surgical intervention. The median length of stay was 3.0days (range 2-13). Two patients were readmitted within 30 day due to fluid retention and incarcerated umbilical hernia. The percentages of excess body weight loss (EBWL) at 1, 3, 6, 9, 12, and 18months were 18.9, 36.4, 54.5, 67.4, 73.9, and 82.42%, respectively. No mortality occurred in this study. Robotically-assisted laparoscopic technique for BPD/DS is a feasible, safe, and effective alternative for weight loss surgery with excellent outcomes.

What is the Actual Fate of Super-Morbid-Obese Patients Who Undergo Laparoscopic Sleeve Gastrectomy as the First Step of a Two-Stage Weight-Reduction Operative Strategy?

The overall success-rate of the two-stage treatment plan for the treatment of super-morbid obesity has not yet been assessed. We reviewed the long-term results of 41 treated super-morbid-obese patients. Mean initial BMI was 59.5 ± 3.5kg/m(2). Twelve patients (29.3%) achieved after only LSG a BMI <35kg/m(2) (mean 31.9 ± 2). They have lost 78.7 ± 11.8% of excess body weight (EBW). The remaining 28 patients lost 48.1 ± 11.9% of EBW and achieved a mean BMI of 44.2 ± 4.3kg/m(2), thus requiring the second stage. Ten of them (24.4% of the total or 35.7% of those in need), were submitted to laparoscopic Roux-en-Y gastric bypass (LRYGBP). They lost 71.9 ± 4.3% of EBW and have a mean BMI of 33.6 ± 2.7kg/m(2). The 18 remaining patients have a BMI of 42 ± 3.6kg/m(2) and they still suffer from morbid obesity. They have lost 48.5 ± 8.7% of EBW. The mean rate of EBW loss for all the available 39 patients after either LSG or both LSG and LRYGBP has been 63.2 ± 16.5% after a mean follow-up of 42.8 ± 19.5months. Out of 41 patients, 1 died, 1 was lost to follow-up, 21 (51.2%) achieved "healthy" BMIs and 18 (44%) still require LRYGBP. The rate of cure of morbid obesity was 51.2%. A remaining 44% of super-morbid obese patients still need the completion LRYGBP but have not undergone it. Half of these patients have lost >50% of their EBW. The two-stage strategy is an effective treatment plan for super-morbid obesity. A less patient-dependent strategy may be needed for a subset of patients.

PMO-049 Pre-operative weight loss in patients undergoing laparoscopic gastric bypass or band

IntroductionTo evaluate the number of patients that achieved loss of at least 10% of their excess body weight prior to undergoing laparoscopic gastric bypass or gastric band surgery.MethodsForty consecutive patients...

PMO-052 Sleeve gastrectomy for obesity: a systematic review

IntroductionSleeve gastrectomy has become an accepted and popular bariatric procedure world wide. Weight loss is achieved through restrictive and endocrine mechanisms. We aimed to evaluate the efficiency of excess weight...