Laparoscopic Biliopancreatic Diversion Research Articles

Outcomes and Complications after Biliopancreatic Diversion Based on Age

Objectives: Although many risk factors affecting outcomes have been identified, the effect of age on weight loss and perioperative complications was not adequately investigated. Advanced age has been reported to be independently associated with increased complications and inferior weight loss outcome. This study was designed to compare the perioperative complications, and weight loss result after biliopancreatic diversion based on age. Methods: Data of all patients who underwent robotically-assisted laparoscopic biliopancreatic diversion between 2008 and 2011 were reviewed. The patients were divided into the following three age groups for comparison: age 20- 35 years (group A), age 36-50 years (group B), and age 51-72 years (group C). Results: A total of 107 patients were included, with no significant differences in gender, and preoperative BMI among the groups. The oldest group (C) had a statistically significant higher number of preoperative comorbidities, compared with those in groups A and B. No statistically significant differences were found in the mean operative-time or length of stay. There were no intraoperative or 30-day major complications. Percentage of excess weight loss at 1,3,6,9,12, and 18 months postoperatively are comparable among groups. No mortality occurred in this series. Conclusions: Despite a higher number of preoperative comorbidities, older patients perform as well as their younger counterparts with respect to perioperative complications and weight loss outcome.

Impact of minimally invasive/bariatric surgery fellowship on perioperative complications and outcomes in the first year of practice

Background:Several reports have described worse perioperative outcomes of laparoscopic gastric bypass procedure during learning curve, which improved after completion of one-year fellowship training.Aims:The aim of this study was to evaluate the immediate impact of fellowship training on perioperative complications and outcomes of various bariatric procedures.Materials and Methods:One hundred initial patients who underwent laparoscopic gastric banding, laparoscopic Roux-en-Y gastric bypass, laparoscopic vertical sleeve gastrectomy, and robotically-assisted laparoscopic biliopancreatic diversion with duodenal switch by a single fellowship trained surgeon were analyzed.Results:Overall average Body Mass Index (BMI) of the patients was 45.9 kg/m2, age was 47.5 years, and the American Society of Anesthesiologist Score was 2.89. There were no intraoperative, major 30-day complications, or open conversions. Average operative time was 62 minutes in gastric banding, 160 minutes in gastric bypass, 119 minutes in vertical sleeve gastrectomy, and 320 minutes in biliopancreatic diversion. Length of stay ranged from 0.5 day after gastric banding to 3.9 days after biliopancreatic diversion. The perioperative complications and outcomes are comparable with those reported by experienced surgeons. No mortality occurred in this series.Conclusions:Bariatric fellowship ensured skills acquisition for new surgeons to safely and effectively perform various types of bariatric operations, with minimal perioperative complications and excellent outcomes.

Quick fix or long-term cure? Pros and cons of bariatric surgery

The past decade has seen an enormous increase in the number of bariatric, or weight loss, operations performed. This trend is likely to continue, mirroring the epidemic of obesity around the world and its rising prevalence among children. Bariatric surgery is considered by many to be the most effective treatment for obesity in terms of maintenance of long-term weight loss and improvement in obesity-related comorbid conditions. Although overly simplified, the primary mechanisms of the surgical interventions currently utilized to treat obesity are the creation of a restrictive or malabsorptive bowel anatomy. Operations based on these mechanisms include the laparoscopic adjustable gastric band and laparoscopic vertical sleeve gastrectomy (considered primarily restrictive operations), the laparoscopic biliopancreatic diversion with or without a duodenal switch (primarily malabsorptive operation), and the laparoscopic Roux-en-Y gastric bypass (considered a combination restrictive and selective malabsorptive procedure). Each operation has pros and cons. Important considerations, for the patient and surgeon alike, in the decision to proceed with bariatric surgery include the technical aspects of the operation, postoperative complications including long-term nutritional problems, magnitude of initial and sustained weight loss desired, and correction of obesity-related comorbidities. Herein, the pros and cons of the contemporary laparoscopic bariatric operations are reviewed and ongoing controversies relating to bariatric surgery are discussed: appropriate patient selection, appropriate operation selection for an individual patient, surgeon selection, and how to measure success after surgery.

Revisional surgery after failed laparoscopic adjustable gastric banding: a systematic review

Laparoscopic adjustable gastric banding (LAGB) has emerged as one of the most commonly performed bariatric procedures worldwide. Unfortunately, revisional surgery is required in 20-30 % of cases. Several revisional strategies have been proposed, but there is no consensus regarding the best surgical option. This systematic review was designed to determine which revisional surgery (laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, or laparoscopic biliopancreatic diversion with duodenal switch) is best suited to enhance weight loss following failed LAGB due to complications or inadequate weight loss. EMBASE, MEDLINE, PsycINFO, and Cochrane Clinical Trials were searched using the most comprehensive timeline for each database. A total of 24 relevant articles were identified. Two investigators independently extracted data, and differences were resolved by consensus. The weighted means were calculated for weight loss measurements. A total of 106, 514, and 71 patients underwent conversion from LAGB to laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass (LRYGB), and laparoscopic biliopancreatic diversion and duodenal switch (BPDDS), respectively. Before revisional surgery, the weighted mean body mass index (BMI) was 38.8 (6.9), 43.3 (8.1), and 41.3 (7.2) kg/m(2) for the LSG, LRYGB, and BPDDS groups, respectively. The majority of data was reported at 12-24 months follow-up. The mean BMI within this interval was 28 (10.5), 32.2 (6.4), and 33 (5.7) kg/m(2) for the LSG, LRYGB, and BPDDS groups, respectively. In addition, the mean excess weight loss (EWL) was 22 % (2.8), 57.8 % (11.7), 47.1 % (14) for the LSG, LRYGB, and BPDDS groups, respectively. The EWL reached 78.4 % (35) in the BPPDS group after 2-year follow-up. Failed LAGB is best managed with conversion to another bariatric procedure. Stable weight loss occurs with salvage LRYGB. Although results for revisional BPPDS appear promising, additional research, with higher methodological quality, is needed.

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.

Multifactorial Analysis of the Learning Curve for Robot-Assisted Laparoscopic Biliopancreatic Diversion With Duodenal Switch

To assess the impact of surgeon, patient, and case-specific factors on the learning curve of robot-assisted laparoscopic biliopancreatic diversion with duodenal switch (RA-LBPD/DS). The BPD/DS has better resolution of diabetes and hypercholesterolemia, and the best long-term weight loss compared to the laparoscopic gastric band or the Roux-en-Y gastric bypass. Despite excellent results, the BPD/DS is least commonly performed because of greater malabsorption, longer operative duration, and higher technical complication rates. A reduction in technical complications and operative duration will enable the BPD/DS to be offered more frequently. Consecutive patients (N = 120) undergoing RA-LBPD/DS between October 2000 and August 2008 were analyzed using univariate and multivariate logistic regression to determine the influence of surgeon and patient factors on complications and operative duration. Independent variables were case number, age, gender, body mass index, American Society of Anesthesiologists (ASA) score, difficult anatomy, and need for extensive adhesiolysis. Dependent variables were complications (leaks, bleeding, and conversion) and operative duration. The best-fit model predicted the risk factors for complications, and a risk-adjusted cumulative sum analysis estimated the learning curve. : Operative duration decreased an average of 3 minutes with each successive case (P < 0.001, R² = 0.63) and with patient's female gender. Adhesiolysis, difficult anatomy, liver biopsy, and higher ASA score increased operative duration. The incidence of high blood loss (13.3%), conversion (2.2%), and leaks (5.8%) were experienced by a total of 22 patients (18.3%). There was no mortality. Complications declined after 50 cases and were strongly predicted by increasing surgeon case number. The learning curve for the RA-LBPD/DS is 50 cases. Risk factors influencing outcomes were identified.

Robotically-assisted Laparoscopic Biliopancreatic Diversion With Duodenal Switch. Initial Experience and Outcomes from a Teaching Hospital

Robotically-assisted Laparoscopic Biliopancreatic Diversion With Duodenal Switch. Initial Experience and Outcomes from a Teaching Hospital

Petersen hernia complicating laparoscopic duodenal switch

l p t b Petersen type hernias have become increasingly recognized with the worldwide adoption of laparoscopic gastric bypass. So-called Petersen’s hernia (PH) is contemporarily defined as an internal hernia through the space between the mesentery of the alimentary limb and the transverse mesocolon. PH can be classified by type and symptoms [1]. No level I data are available to inform surgeons whether Petersen’s space should be closed at primary surgery, and this has led to a lively debate in published studies [2–6]. However, it is clear that PH can present nonspecifically, is diagnostically challenging, and can rapidly cause fatal complications. Our unit policy is to close Petersen’s space at gastric bypass. Similar to gastric bypass, Petersen’s space is created during laparoscopic biliopancreatic diversion and duodenal switch (BPD/DS) procedure (Fig. 1). A paucity of data is available regarding PH and laparoscopic BPD/DS. We present 4 cases of symptomatic PH complicating laparoscopic BPD/DS (Table 1).

Syndrome de Prader-Willi : traitement chirurgical par bypass biliopancréatique coelioscopique

Prader-Willi syndrome (PWS) is a genetic disorder characterized by neonatal hypotonia, short stature, hypogonadism, mental retardation and compulsive hyperphagia partially explained by high plasma ghrelin, an orexigenic substance secreted by the stomach. Obesity is a major cause of increased morbidity and mortality in these patients. Dietary restriction alone is unable to achieve a permanent weight loss, thus surgical treatment has been attempted, but gastric restrictive operations were unsuccessful. In a small number of patients, favourable results have been reported with biliopancreatic diversion (BPD). We report a PWS case treated by laparoscopic BPD. A 28-year-old female PWS patient with morbid obesity (123 kg; BMI: 58 kg/m2) was operated. There was no complication. After 4 years, she lost 22 kg with a BMI of 47 kg/m2. This modest weight loss can be explained by insufficient food compliance. Yet, diabetes mellitus was controlled without insulin. Neither hypoproteinemia nor vitamin deficiency was observed. Laparoscopic BPD was safe, with a benefit regarding diabetes.

Conversion of failed gastric banding into four different bariatric procedures

BackgroundThe most common bariatric operation in Europe, laparoscopic adjustable gastric banding (LAGB), is reported to have a high incidence of long-term complications. Also, insufficient weight loss is reported. The optimal conversion technique is unknown. Our objective was to report our experience in the conversions of failed laparoscopic gastric banding procedures to 4 different bariatric procedures at a university hospital. MethodsFrom March 2006 to December 2010, 630 bariatric operations were performed. Of these patients, 45 underwent conversion of failed LAGB (n = 38) and nonadjustable gastric banding (n = 7). Using a prospectively collected database, we analyzed these procedures. ResultsThe 45 patients underwent laparoscopic conversion of failed LAGB (n = 38) and nonadjustable gastric banding (n = 7) to 4 different procedures. Of the 45 patients, 18 underwent conversion to laparoscopic sleeve gastrectomy, 18 to laparoscopic Roux-en-Y gastric bypass, 7 to laparoscopic biliopancreatic diversion with duodenal switch, and 2 to laparoscopic biliopancreatic diversion. All conversions but 1 were completed laparoscopically. The mean operating time and hospital stay for laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, laparoscopic biliopancreatic diversion with duodenal switch, and biliopancreatic diversion was 111 ± 28 minutes and 4.3 ± 1.4 days, 195 ± 59 minutes and 3.9 ± 1.5 days, 248 ± 113 minutes, and 5.9 ± 2.6 days, and 203 minutes and 6.5 days, respectively. No patient died. Perioperative complications occurred in 4 patients (9.8%). The mean body mass index decreased from 41.5 ± 8 kg/m2 to 31.3 ± 6.8 kg/m2 during a mean follow-up period of 13.7 ± 9.6 months. Although laparoscopic biliopancreatic diversion with and without duodenal switch had the greatest preoperative body mass index, they achieved the greatest excess weight loss. ConclusionConversion of LAGB or nonadjustable gastric banding to laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, and laparoscopic biliopancreatic diversion with or without duodenal switch is feasible and effective to treat the complications of LAGB and to further reduce the weight of morbidly obese patients.

“Vest Over Pants” Abdominoplasty in Post-bariatric Patients

Obesity has become a worldwide metabolic disease, necessitating appropriate treatment. Conservative therapy has shown lack of success long term on managing weight loss and comorbidities. On the other hand, bariatric surgery has demonstrated effectiveness. Unfortunately, bariatric patients experience significant skin excess, laxity, and ptosis which may lead to postural, functional, hygienic, dermatologic, and aesthetic impairments. These can be corrected only with body-contouring surgery. Among these procedures, abdominoplasty is one of the most commonly performed operations. In 1977, Planas presented his "vest over pants" abdominoplasty, which had several advantages over the previous approaches. In this study, the technique was tested on post-bariatric patients. From 2005 to 2008, subsequent to laparoscopic biliopancreatic diversion, a tummy tuck was performed on 35 patients (28 females; 7 males). The patients were followed up for a mean period of 5years. After abdominal contouring, 22 patients had an uneventful recovery and local complications were reported in the other 13 patients. Several advantages of this abdominal lipectomy method were recorded: minimal infection rate and single flap weight; high vascular safety; excellent matching of the flaps' thickness and scar position on the abdomen; minimal cumbersome maneuver and traction of the tissues; relatively short operating and lead time; and discrete comfort for the assistants and surgeon. In conclusion, the "vest over pants" abdominoplasty in post-bariatric patients has been demonstrated to be effective, fast to perform, comfortable for the surgeon, and safe.

Laparoscopic Biliopancreatic Diversion: a Surgical Technique in our Learning Curve

BackgroundWe present our initial experience with the laparoscopic BPD technique for super-obese patients. Recommended tips on the technique are summarized. MethodsA total of 35 super-obese patients were submitted to BPD by laparoscopy in November 2009 and June 2010 for the treatment of morbid obesity. ResultsAll operations were performed by laparoscopy with no need to convert to laparotomy. No mayor complications and mortality related to surgery were observed. ConclusionThe Scopinaro technique can be safely performed in super-obese patients by surgeons with special dedication for bariatric surgery and advanced skills in intracorporeal suturing and knot-tying.

A novel use of endoscopic cutter: Endoscopic retrieval of a retained nasogastric tube following a robotically assisted laparoscopic biliopancreatic diversion with duodenal switch

A nasogastric tube is utilized routinely by many bariatric surgeons to assist creation of gastrojejunal anastomosis during roux-en-y gastric bypass or duodenojejunal anastomosis during biliopancreatic diversion. However, inadvertent stapling or suturing of the nasogastric tube has been known as a potential complication of this technique.We describe a successful endoscopic removal of an inadvertently sutured nasogastric tube at the level of the duodenojejunal anastomosis in a 30-year-old woman undergoing a robotically assisted laparoscopic biliopancreatic diversion with duodenal switch for super morbid obesity.Endoscopic technique is a feasible and safe minimally invasive technique to release a retained nasogastric tube with preservation of the newly created anastomosis. This option gives major advantages of avoiding a re-operation, as well as the potential general anesthetic complications.

Reduction of Imatinib Concentration After Gastric Bypass Surgery

AbstractAbstract 4948Imatinib mesylate is an orally bioavailable inhibitor of several protein tyrosine kinases, including BCR-ABL, which was approved for BCR-ABL–positive CML. This oral agent has approximately 98% oral bioavailability independent of a meal, and it is eliminated by biliary excretion and hepatically metabolized. Better clinical outcomes have been associated with higher steady state imatinib trough levels for both CML and GIST. Because imatinib is absorbed, excreted, and possibly recycled in the gastrointestinal tract, gastrointestinal disorders impairing absorption may hinder achieving therapeutically effective imatinib levels. We present the case of a woman with CML who underwent biliopancreatic diversion with duodenal switch for weight loss leading to a marked reduction in imatinib concentration, and as a consequence, inadequate suppression of her CML. This is a 54 year old obese African American woman who achieved complete hematological remission (CHR), and complete cytogenetics remission (CCyR) and good molecule response with a BCR-ABL/c-ABL ratio of 0.015 (1.5%) with close to therapeutic imatinib trough level at 965 ng/mL prior to gastric bypass surgery on imatinib 400mg daily. The patient underwent laparoscopic biliopancreatic diversion with duodenal switch, concomitant cholecystectomy, and appendectomy. Her adjusted imatinib steady state trough level declined to 166ng/mL, 17% of the pre-surgery level and below the concentration required to suppress BCR-ABL activity leading to a 0.5 log increase in BCR-ABL/c-ABL ratio of 0.083 (8.3%). Escalation of imatinib to 400 mg BID led to imatinib trough level of 734 ng/mL and decrease of BCR-ABL/c-ABL ratio to 0.024 (2.4%), a value comparable to the ratio achieved while on imatinib 400mg daily prior to the gastric bypass surgery. Eventually, our patient lost almost 50kg (close to 45% of her original weight) within a year period. Interestingly, the imatinib level increased to 2124 ng/mL on imatinib 400mg twice a day after the substantial weight loss, supporting the correlation of imatinib level and actual body weight. Her PCR BCR-ABL/c-ABL from peripheral blood still revealed a ratio of 0.072 (7.2%) with high therapeutic imatinib level, and a secondary generation TKI, nilotinib, was initiated at 400mg twice a day. The detail of the clinical course was listed in table below. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Experience of 15 years using the 25-mm flexed end to end anastomosis anvil for safe transoral passage during intracorporeal circular-stapling gastrojejunostomy, esophagogastrostomy, and esophagojejunostomy

I read with interest the article entitled Intracorporeal Circular Stapling Esophagojejunostomy Using the Transorally Inserted OrVilTM After Laparoscopic Total Gastrectomy. The article stated that ‘‘an optimal procedure has yet to be established,’’ referring to the use of a flip-top end to end anastomosis (EEA) for reconstruction after major gastric resections [1]. The authors did not report that this technique has been described since 1995, first for the use of gastrojejunostomy during Roux-en-Y gastric bypass and then for esophagogastrostomies and esophagojejunostomies after proximal or total gastrectomies and various esophagectomies. The OrVilTM product by Covidien (Norwalk, CT) is a commercialization of the concept and method I designed in 1995 and used clinically in 1996, applying a conventional 25-mm curved end to end anastomosis (CEEA) anvil from which the spring was removed, the cutting plate depressed to allow free movement, and the anvil shaft invaginated into a cut no. 18 nasogastric tube. A prolene suture was passed through the tube and orifice at the tip of the shaft and into the circular metal plate to maintain the anvil in a flexed position for an easy transoral passage in the oropharynx and to prevent accidental deployment (Fig. 1A, B) [2]. This was an improvement over the transoral passage of a 21-mm EEA described by Wittgrove et al. [3] because the 21-mm EEA was not inserted in a flexed position, which despite the smaller EEA diameter could result in disruption or damage to the integrity of the esophageal wall or lodging of the EEA along its passage. It has subsequently been demonstrated that the 21-mm EEA results in a much higher stricture rate [4] and probably is associated with a higher leak rate due to the smaller staple line surface area, which may not cover the perforated tube site if stapling is performed excentrically. I have used the technique described in 1996 very safely in more than 3,000 cases, and others have used it in probably more than 100,000 procedures worldwide for the aforementioned indications, including complex esophagogastric revisions and repair of strictures [5–7]. Moreover, this technique has been used for duodenoileostomy anastomosis in laparoscopic biliopancreatic diversion with a duodenal switch when the ileum is wide enough to accommodate a 25-mm EEA, as well as for duodenojejunal or jejunojejunal bypass and transanally for reversed coloanal or colorectal anastomosis [8].

Laparoscopic Versus Open Biliopancreatic Diversion: A Prospective Comparative Study

Bariatric surgery is playing an increasingly important role in our society. The surgical approach should be chosen in consistent with the patients' problem. The purpose of this study was to compare surgical outcomes in patients who underwent laparoscopic Scopinaro's biliopancreatic diversion (BPD) versus open BPD in our institute experience. Eighty patients were enrolled and divided in two groups: laparoscopic group (VL) and open group (OP), with 40 patients in each group during two calendar years 2006-2007. We performed the same technique for both groups using the same staplers for anastomosis, with the same measurements for alimentary and common limbs in both groups. We compared the following variables in the two groups: operative time, intra and early postoperative complications, postoperative pain, consumption of analgesics, recovery of intestinal function, days to removal of NG tube and start of oral intake, hospital stay, and late complication-incisional hernia incidence. We found statistically significant reduction in favor of laparoscopic group regarding reduction in postoperative pain, consumption of analgesics, incidence of incisional hernia, operative time, and hospital stay-with early removal of NG tube and early oral intake. We did not find any statistically significant difference regarding intra, immediate and early postoperative complications and recovery of intestinal functions. Laparoscopic BPD is a safe technique; has good results without affecting the duration of the intervention; and ensures less postoperative pain with rapid functional recovery, less hospital stay, and drastic reduction of incisional hernia incidence.

Randomized clinical trial of laparoscopic gastric bypass versus laparoscopic duodenal switch for superobesity

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic biliopancreatic diversion with duodenal switch (LDS) are surgical options for superobesity. A randomized trial was conducted to evaluate perioperative (30-day) safety and 1-year results. Sixty patients with a body mass index (BMI) of 50-60 kg/m(2) were randomized to LRYGB or LDS. BMI, percentage of excess BMI lost, complications and readmissions were compared between groups. Patient characteristics were similar in the two groups. Mean operating time was 91 min for LRYGB and 206 min for LDS (P < 0.001). One LDS was converted to open surgery. Early complications occurred in four patients undergoing LRYGB and seven having LDS (P = 0.327), with no deaths. Median stay was 2 days after LRYGB and 4 days after LDS (P < 0.001). Four and nine patients respectively had late complications (P = 0.121). Mean BMI at 1 year decreased from 54.8 to 38.5 kg/m(2) after LRYGB and from 55.2 to 32.5 kg/m(2) after LDS; percentage of excess BMI lost was greater after LDS (74.8 versus 54.4 per cent; P < 0.001). LRYGB and LDS can be performed with comparable perioperative safety in superobese patients. LDS provides greater weight loss in the first year.

Vitamin status after bariatric surgery: a randomized study of gastric bypass and duodenal switch

Background:Bariatric surgery is widely performed to induce weight loss. Objective:The objective was to examine changes in vitamin status after 2 bariatric surgical techniques. Design:A randomized controlled trial was conducted in 2 Scandinavian hospitals. The subjects were 60 superobese patients [body mass index (BMI; in kg/m2): 50–60]. The surgical interventions were either laparoscopic Roux-en-Y gastric bypass or laparoscopic biliopancreatic diversion with duodenal switch. All patients received multivitamins, iron, calcium, and vitamin D supplements. Gastric bypass patients also received a vitamin B-12 substitute. The patients were examined before surgery and 6 wk, 6 mo, and 1 y after surgery. Results:Of 60 surgically treated patients, 59 completed the follow-up. After surgery, duodenal switch patients had lower mean vitamin A and 25-hydroxyvitamin D concentrations and a steeper decline in thiamine concentrations than did the gastric bypass patients. Other vitamins (riboflavin, vitamin B-6, vitamin C, and vitamin E adjusted for serum lipids) did not change differently in the surgical groups, and concentrations were either stable or increased. Furthermore, duodenal switch patients had lower hemoglobin and total cholesterol concentrations and a lower BMI (mean reduction: 41% compared with 30%) than did gastric bypass patients 1 y after surgery. Additional dietary supplement use was more frequent among duodenal switch patients (55%) than among gastric bypass patients (26%). Conclusions:Compared with gastric bypass, duodenal switch may be associated with a greater risk of vitamin A and D deficiencies in the first year after surgery and of thiamine deficiency in the initial months after surgery. Patients who undergo these 2 surgical interventions may require different monitoring and supplementation regimens in the first year after surgery. This trial was registered at clinicaltrials.gov as NCT00327912.

Laparoscopic Sleeve Gastrectomy as Revisional Procedure for Failed Gastric Banding and Vertical Banded Gastroplasty

The problem of revision of failed gastric banding (GB) and vertical banded gastroplasty (VBG) procedures has become a common situation in bariatric surgery. Laparoscopic sleeve gastrectomy (LSG) has been recently used to revise failed restrictive procedures. The objective of this study is to evaluate the results of LSG as revisional procedure for failed GB and VBG. A prospective held database was questioned regarding patients' demographic, indication for revision, conversion to open surgery, morbidity, percentage of excess weight loss (%EWL), evolution of comorbidities, and need for a second procedure after LSG. Forty-one patients, 34 women and seven men with a mean age of 42 years (range 19 to 63 years) and a mean body mass index at 49.9 kg/m(2) (range 35.9-63 kg/m(2)), underwent laparoscopic conversion of GB (36 patients) and VBG (five patients) into LSG. Indication for revisional surgery was insufficient weight loss in all the cases. All procedures were completed laparoscopically. There was no mortality and five patients (12.2%) developed complications (high leak, one patient; intra-abdominal abscess, three patients; and complicated incisional hernia, one patient). At a mean follow-up of 13.4 months, %EWL is on average 42.7% (range 4-76.1%). Six patients had a second procedure (four had laparoscopic duodenal switch, one had laparoscopic Roux-en-Y gastric bypass, and one had laparoscopic biliopancreatic diversion). Conversion of GB and VBG into LSG is feasible and safe. LSG is effective in the short term with a mean %EWL of 42.7% at 13.4 months. Long-term results of LSG as revisional procedure are awaited to establish its efficacy in the long term.

V-13: Laparoscopic revision of biliopancreatic diversion and management of postoperative complications

We present the case of a 58-year-old woman who initially underwent laparoscopic biliopancreatic diversion with duodenal switch (BPD-DS) for severe obesity in 2001. The patient had excellent initial weight loss but recently noted decreasing restriction accompanied by weight regain along with excessive diarrhea that was refractory to medical treatment. We performed a laparoscopic revision of her BPD=DS to lengthen her common channel by 50% and reduce the volume of her sleeve gastrectomy. Postoperatively, she developed gastric obstruction that failed conservative management and required operative removal of the imbricating suture along the sleeve gastrectomy staple line. The patient had a slow recovery after discharge from the hospital and was readmitted on post operative day 10 for emesis. These symptoms ultimately resolved with medical management. At a subsequent clinic visit one and a half months later, the patient's diet tolerance had substantially improved. Her weight decreased forty pounds and her BMI decreased from 36 to 30 kg/m2.