Mean Percentage Of Excess Weight Loss Research Articles

Effect of adjustable gastric banding on changes in gastroesophageal reflux disease (GERD) and quality of life

Objective:Bariatric surgery is an effective treatment for the reduction of weight in obese patients (BMI ≥ 40 kg/m2 or 30 kg/m2 with ≥1 comorbidities), who are refractory to behavioral and medical therapies. This study examined the effect of the adjustable gastric band (AGB) system on changes in gastroesophageal reflux disease (GERD) and patient-reported outcomes, including measures of quality of life.Methods:Two-year interim analysis of patients (N = 171) in the 5 year, prospective APEX study who reported GERD prior to the AGB procedure. An unrecorded number of hiatal hernia repairs were conducted during the APEX study.Results:At baseline, 171 of 395 patients (43%) reported GERD requiring daily medical therapy. After 2 years, 122 patients had sufficient data to assess outcome (71%). Complete resolution of GERD was reported in 98 patients (80%), improvement in 13 (11%), no change in 9 (7%), and worsening in 2 (2%). Overall, 91% of GERD patients experienced resolution and/or improvement of GERD. Baseline BMI was not significantly different among the GERD response categories (resolved, improved, and stable/worse), p = 0.4581. Mean ΔBMI and percentage excess weight loss (%EWL) were: −8.8 kg/m2/−0.9%, −11.4 kg/m2/−53.9%, −6.4 kg/m2/−36.1%, and −7.1 kg/m2/−31.2%, respectively. There were no significant differences in reductions in BMI or %EWL between responder groups (resolved versus stable/worse ΔBMI p = 0.1031, %EWL p = 0.0667 OR resolved/improved versus stable/worse ΔBMI p = 0.0918, %EWL p = 0.0552). After 2 years, resolution or improvement occurred in pre-existing comorbidities: type 2 diabetes (96%), hypertension (91%), hyperlipidemia (77%), obstructive sleep apnea (86%), osteoarthritis (93%), and depression (75%). Patient satisfaction with AGB was assessed as: very satisfied/satisfied (87%), very satisfied (50%), dissatisfied (5.0%). Quality of life measured by the Obesity and Weight-Loss Quality of Life Instrument (GERD patients) significantly improved from baseline.Conclusion:Obese patients with GERD had meaningful improvement in patient-reported outcomes with the AGB system. In addition, other obesity-related comorbidities and measures of quality of life improved.

Single-stage laparoscopic sleeve gastrectomy: safety and efficacy in the super-obese

BackgroundLaparoscopic sleeve gastrectomy (LSG) is increasingly used as a single-stage bariatric procedure. However, its safety and efficacy in super-obese patients (body mass index [BMI] > 50 kg/m2) is less well defined. This series reports on 400 consecutive patients who underwent LSG at our institution, to evaluate safety and efficacy in the super-obese. Materials and methodsWe performed a retrospective review of prospectively collected data on 400 consecutive patients who underwent LSG at our institution. We analyzed baseline demographic data, median length of hospital stay, complications, length of follow-up, weight loss, and comorbidity resolution. We graded complications according to the Clavien-Dindo classification system. We classified patients as super-obese and non–super-obese and compared outcomes between groups. We used the two-tailed t-test and Fisher’s exact test as necessary. ResultsThere were 400 patients, 291 of whom were female (73%). The mean age was 44 y (standard deviation [SD] ± 9 y). The mean preoperative weight and BMI were 140 kg (SD ± 31 kg) and 49 kg/m2 (SD ± 9 kg/m2), respectively. There were 67 complications (16%) in total. The major complication rate was 7.2%, with one recorded death. The median length of hospital stay was 3 d, and the mean follow-up period was 1 y. A total of 170 patients (43%) were super-obese, with a mean preoperative BMI of 56 kg/m2 (SD ± 5 kg/m2). The mean absolute weight loss (59 versus 36.7 kg; P < 0.01) and percentage excess weight loss (58.9% versus 45.9%; P < 0.01) was significantly higher in the super-obese. The mean postoperative BMI for super-obese patients was 38.9 kg/m2. There was no difference between groups in the incidence of major complications (8.2% versus 6.5%; P = 0.56). ConclusionLaparoscopic sleeve gastrectomy is safe and effective in the super-obese, with acceptable weight loss and no increase in the major complication rate.

Staple-Line Reinforcement with a Thrombin Matrix During Laparoscopic Sleeve Gastrectomy for Morbid Obesity: A Case Series

Laparoscopic sleeve gastrectomy (LSG) represents a valid option for morbidly obese patients, either as a primary or as a staged procedure. Staple-line reinforcement (SLR) is strongly advocated to decrease the chance of bleeding. The aim of this article is to report our experience with a new technique of SLR using a thrombin-gelatin matrix in a series of morbidly obese patients subjected to LSG. Patients subjected to LSG using a thrombin-gelatin matrix for SLR from April 2010 to April 2011 were included in the study. Each patient's record was registered and prospectively collected for the analysis. Seventy-four patients were subjected to LSG using a thrombin matrix for SLR. There were 56 female and 18 male subjects with a mean age of 44.8 years (range, 16-64 years). Mean preoperative body mass index was 46.2 kg/m(2) (range, 40-72 kg/m(2)). Mean operative time was 74.4 minutes (range, 58-96 minutes). Mean time for application of the thrombin matrix was 4.8 minutes (range, 3.2-6.6 minutes). Mean postoperative hospital stay was 3.4 days (range, 2-62 days). Mean follow-up was 8.2 months (range, 3-12 months). Mean postoperative body mass index was 36.2 kg/m(2) (range, 30-42 kg/m(2)), and mean percentage excess weight loss was 34.2% (range, 28.4%-42.8%). We observed two major postoperative complications (2.7%): One gastric stump leak (1.3%) and one major bleeding from the trocar site (1.3%), both successfully treated by laparoscopic re-exploration. LSG with a thrombin matrix for SLR is a safe operation and a valid alternative to other well-established techniques.

Is Laparoscopic Duodenojejunal Bypass with Sleeve an Effective Alternative to Roux En Y Gastric Bypass in Morbidly Obese Patients: Preliminary Results of a Randomized Trial

The incidence of obesity and related metabolic disorders in India and that of stomach carcinoma is one of the highest in the world. Hence, one requires a procedure that allows postoperative surveillance of the stomach with the best outcomes in terms of weight control and resolution of co-morbidities. Here, we compare one such procedure, duodenojejunal bypass with sleeve against the standard Roux-en Y gastric bypass. Fifty-seven patients who were selected for a bypass procedure were randomized into two groups of laparoscopic duodenojejunal bypass with sleeve (DJB) and laparoscopic Roux en Y gastric bypass. The limb lengths were similar in both the groups, and the sleeve was done over a 36F bougie. The mean body mass index and percent excess weight loss at the end of 3, 6, and 12months between the groups were not statistically significant. The operating times were higher in the DJB group. The rate of resolution of diabetes, hypertension, and dyslipidemias were also similar with no statistical significance. There was 100% resolution of dyslipidemias in both groups. There was one patient in the DJB group who presented with internal herniation 1month post-op and was managed surgically. There was no mortality in both the groups. Laparoscopic duodenojejunal with sleeve gastrectomy, a procedure which combines the principles and advantages of sleeve gastrectomy and foregut hypothesis, is a safe and effective alternative to gastric bypass in weight reduction and resolution of co-morbidities especially for Asian countries. But, long-term follow-up is required.

Laparoscopic Sleeve Gastrectomy with an Extensive Posterior Mobilization: Technique and Preliminary Results

Laparoscopic sleeve gastrectomy (LSG) is becoming increasingly popular as a stand-alone procedure for the treatment of morbidly obese patients. A direct posterior approach to the angle of His was developed at our department to improve visualization of the difficult dissection of the short gastric vessels and to facilitate proper mobilization of the stomach around the left crus enabling safe realization of a tight sleeve. The technique and its preliminary results are described. LSG by posterior approach was performed in a consecutive series of 445 (110 male/335 female, age 18-63years, mean body mass index 46kg/m(2) (range 35-76)) patients between 2007 and 2010. Weight loss defined as mean percent excess weight loss (%EWL) was 71% (±26%) at 1year, 69% (±25%) at 2years, and 55% (±27%) at 3years. Sixteen patients (4%) developed postoperative intra-abdominal hematoma, 8 patients (2%) anastomotic leakage, and 6 patients intra-abdominal abscess (1%), requiring reoperation in 20 patients (4%). Five patients (1%) had pulmonary embolism. Thirty-day mortality rate was 0.2%. LSG by the posterior approach is a safe and effective procedure, enabling a tight sleeve formation leading to satisfactory %EWL results. Since long-term results of LSG are unknown, further studies are needed to define the exact place of the LSG as a stand-alone bariatric procedure.

Gastric Band Erosion in 63 Cases: Endoscopic Removal and Rebanding Evaluated

Laparoscopic adjustable gastric banding (LAGB) remains the most popular bariatric procedure performed in Australia and Europe. Gastric band erosion is a significant complication that results in band removal. The aim of this study is to assess the prevalence of band erosion and its subsequent management with a particular focus on rebanding results. Patients who underwent LAGB in a prospective cohort study from August 1996 to October 2010 were evaluated. Patients that developed band erosion were identified and clinical presentations, band characteristics and subsequent management were evaluated. One thousand eight hundred seventy-four morbidly obese patients underwent LAGB. Band erosion developed in 63 patients (3.4%). Median preoperative BMI was 41.5kg/m(2) (range 30-61kg/m(2)). Median time from operation to diagnosis was 39months (range 6-132months). Twenty nine patients (46%) were asymptomatic (sudden loss of restriction, weight gain, turbid fluid, or absence of fluid). Symptoms included abdominal pain in 24 (38%), obstruction in 7 (11%), recurrent port infection in 5 (8%), reflux symptoms in 2 (3%) and sepsis in 2 (3%). Fourteen patients (22%) had discolouration of the fluid in their band. Endoscopic removal was attempted in 50 patients with successful removal in 46 (92%). Median number of endoscopies prior to removal was 1.0 (range 1-5). The median duration of the procedure was 46min (range 17-118min). Rebanding was performed in 29 patients and 5 (17%) experienced a second erosion. Mean percentage excess weight loss was 54% in the remaining 22 patients with at least 3months follow-up. Band erosion prevalence was 3.4%. Endoscopic removal of eroded gastric bands was proven safe and effective. Band erosion is now preferably managed endoscopically in our institution. Rebanding following erosion results in acceptable weight loss but an unacceptable reerosion rate.

Early results after introduction of biliopancreatic diversion/duodenal switch at a military bariatric center

Background Biliopancreatic diversion with duodenal switch (BPD/DS) is one of the most effective procedures in terms of weight loss and durability. It is also one of the most complex and highest risk bariatric procedures. The authors report their initial experience with BPD/DS. Methods A retrospective review of all patients undergoing BPD/DS was performed, including a descriptive analysis of demographics, operative data, complications, and outcomes. Results were also compared with those among a group of 100 patients undergoing laparoscopic gastric bypass (LGB). Results Forty-three patients were identified. Mean preoperative body mass index was 52 kg/m 2, and 56% of patients had body mass indexes > 50 kg/m 2. Twenty (47%) were attempted laparoscopically, with 5 (25%) requiring conversion to open approach. Overall mean operative time was 269 minutes, with no significant difference between laparoscopic (256 minutes) and open (280 minutes). No major intraoperative complications occurred. Major postoperative complications included 4 gastric sleeve leaks, 2 small bowel obstructions, 1 intra-abdominal hemorrhage, and 1 duodenal stump leak. There was 1 death. Mean percentage excess body weight loss was 85% at 1 year. No patients developed severe malabsorptive symptoms or evidence of protein malnutrition. BPD/DS was associated with longer operative times and higher complication rates ( P < .05 for both) compared with LGB but had significantly greater weight loss at 1 year ( P < .05). Conclusion BPD/DS is a complex procedure associated with increased operative times, increased risk for conversion from laparoscopic to open approach, and higher postoperative complication rates. However, it results in significantly greater weight loss than LGB without major adverse nutritional impact.

Improvement of migraine headaches in severely obese patients after bariatric surgery

Research increasingly suggests that obesity is an exacerbating factor for migraine. However, it is less clear whether weight loss may help to alleviate migraine in obese individuals. We examined whether weight loss after bariatric surgery is associated with improvements in migraine headaches. In this prospective observational study, 24 patients who had migraine according to the ID-Migraine screener were assessed before and 6 months after bariatric surgery. At both time points, patients had their weight measured and reported on frequency of headache days, average headache pain severity, and headache-related disability over the past 90 days via the Migraine Disability Assessment questionnaire. Changes in headache measures and the relation of weight loss to these changes were assessed using paired-sample t tests and logistic regression, respectively. Patients were mostly female (88%), middle-aged (mean age 39.3), and severely obese (mean body mass index 46.6) at baseline. Mean (±SD) number of headache days was reduced from 11.1 ± 10.3 preoperatively to 6.7 ± 8.2 postoperatively (p < 0.05), after a mean percent excess weight loss (%EWL) of 49.4%. The odds of experiencing a ≥50% reduction in headache days was related to greater %EWL, independent of surgery type (p < 0.05). Reductions in severity were also observed (p < 0.05) and the number of patients reporting moderate to severe disability decreased from 12 (50.0%) before surgery to 3 (12.5%) after surgery (p < 0.01). Severely obese migraineurs experience marked alleviation of headaches after significant weight reduction via bariatric surgery. Future studies are needed to determine whether more modest, behaviorally produced weight losses can effect similar migraine improvements.

Changes in Satiety, Supra- and Infraband Transit, and Gastric Emptying Following Laparoscopic Adjustable Gastric Banding: A Prospective Follow-up Study

Laparoscopic adjustable gastric banding (LAGB) induces and sustains weight loss, likely by activating the peripheral satiety mechanism. Recent data suggests that food is not retained above the optimally adjusted LAGB, suggesting that an alternate mechanism is inducing satiety. How transit and gastric emptying change following LAGB and correlate with satiety and weight loss have not been adequately defined. LAGB patients underwent preoperative and 12-month follow-up nuclear scintigraphic assessments of esophageal transit and gastric emptying. A new technique that allowed the calculation of emptying times and transit through the supra- and infraband compartments was used to assess emptying and transit patterns postoperatively. Postoperatively, patients reported increased satiety both after a standard fast (3.7 ± 2.3 vs. 4.8 ± 2.1, p = 0.04) and following a standard semisolid meal (5.9 vs. 7.8 ± 1.7, p = 0.003). The mean percent excess weight loss was 48.5 ± 23.2%. The gastric emptying half-time (minutes) did not change significantly (63.5 ± 41.1 vs. 73.3 ± 26.8, p = 0.64). Semisolid transit into the infraband stomach was delayed briefly postoperatively in more patients (11 vs. 2, p = 0.001). There was minimal retention of the meal above the LAGB 2 min after commencing the gastric emptying study (median, 3%; interquartile range, 1.75-10); therefore, an emptying half-time of the supraband region could not be defined. Weight loss, satiety, and early satiation following LAGB were associated with briefly delayed bolus transit into the infraband stomach. Retention of the semisolid meal above the LAGB was not observed. This is further evidence that suggests satiety develops following LAGB without physical restriction of meal size.

Laparoscopic Sleeve Gastrectomy is a Safe and Effective Bariatric Procedure for the Lower BMI (35.0–43.0 kg/m2) Population

BackgroundThe laparoscopic vertical sleeve gastrectomy (LSG) is derived from the biliopancreatic diversion with duodenal switch operation (Marceau et al., Obes Surg 3:29–35, 1993; Hess and Hess, Obes Surg 8:267–82, 1998; Chu et al., Surg Endosc 16:S069, 2002). Later, LSG was advocated as the first step of a two-stage procedure for super-obese patients (Regan et al., Obes Surg 13:861–4, 2003; Cottam et al., Surg Endosc 20:859–63, 2006). However, recent support is mounting that continues to establish LSG as the definitive procedure for surgical treatment of morbid obesity. We will report our experience with the LSG as a primary bariatric procedure and evaluate if this operation is suitable as a stand-alone procedure.MethodsThe study is a nonrandomized retrospective analysis of 204 patients from a single surgeon operated between July 2006 and April 2010. The study comprises of 155 women and 49 men with a mean age of 45 years (range, 19–70 years), a mean preoperative weight of 126.6 kg, and body mass index (BMI) of 45.7 kg/m2.ResultsThe mean percent excess weight loss (%EWL) was 49.9% (n = 159), 64.2% (n = 138), 67.9% (n = 77), 62.4% (n = 34), and 62.2% (n = 9) at 3, 6, 12, 24, and 36 months, respectively. For patients with BMI ≤43.0, the mean postoperative %EWL was 58.9% (n = 72), 74.1% (n = 67), 75.8% (n = 39), 72.1% (n = 17), and 78.7% (n = 5) at 3, 6, 12, 24, and 36 months, respectively. Operative complications include leak (0.0%), abscess (0.5%), hemorrhage (1.0%), sleeve stricture (1.0%), and severe gastroesphogeal reflux disease with need to convert to laparoscopic Roux-en-Y gastric bypass (0.5%).ConclusionsLSG yields excellent outcomes with low complication rates for morbidly obese patients. We advocate LSG as a safe and effective stand-alone procedure, especially with the lower BMI population (BMI 35.0–43.0 kg/m2).

Laparoscopic adjustable gastric banding (LAGB): surgical results and 5-year follow-up

LAGB is a technique increasingly used in the USA. The aim of this study is to analyze the 5-year outcome in terms of weight loss and complications. We reviewed our prospective electronic database for all patients undergoing LAGB between 2002 and 2007. We assessed weight progression, complications, and reoperations. We performed 199 cases during this period (70.4% females). Mean age was 37.8 ± 12.4 years. Preoperative body mass index (BMI) was 36.0 ± 3.8 kg/m(2). Preoperative comorbidities were dyslipidemia in 52.3%, insulin resistance in 30.7%, arterial hypertension in 24.6%, and type 2 diabetes in 5.5%. There were no conversions to open technique. Early complications were observed in two patients (1%): one hemoperitoneum and one ileitis. Mortality was 0%. Late complication rate was 33.6% (18.0% related to the band). Reoperation was required in 40 patients (20.1%). Laparoscopic repositioning was done in seven patients, and port/reservoir revision was done in five patients. Band removal was required in 28 patients, due to inadequate weight loss in 9, slippage in 9, gastric erosion in 1, bowel obstruction in 1, acute stomach dilatation in 1, and food intolerance in 7. Twenty of these patients underwent revisional surgery: sleeve gastrectomy in 12 and laparoscopic Roux-en-Y gastric bypass in 8 cases. Unrelated band complication was seen in 15.6%, mainly due to anemia (7.5%), alopecia (4.5%), and cholelithiasis (3.5%). With a median follow-up of 48 months (1-72 months), 75, 60, and 95% of patients were available for follow-up at 1, 3, and 5 years, respectively. Mean percent excess weight loss (%EWL) at 1, 3, and 5 years was 58.8 ± 30.0%, 56.8 ± 35.0%, and 58.4 ± 46.6%, respectively. However, failure rate (%EWL <50%) at 1, 3, and 5 years was 40.4, 43.5, and 46.3%, respectively. LAGB has low perioperative morbidity. However, its late complications are significant, and inadequate weight loss can be as high as 46.3% after 5 years.

Revision of Failed Bariatric Procedures to Roux-en-Y Gastric Bypass (RYGB)

Bariatric surgery for morbid obesity has been established as an effective treatment method and has been shown to be associated with resolution of co-morbidities. Despite its success, some patients may require revision because of weight regain or mechanical complications. From September 2005 to December 2009, 42 patients underwent revisional Roux-en-Y gastric bypass (RYGB). All procedures were performed by one surgeon. Demographics, indications for revision, complications, and weight loss were reviewed. Thirty-seven patients were treated with laparoscopic (n = 36) or open (n = 1) RYGB after failed laparoscopic adjustable gastric banding. Four patient were treated with laparoscopic (n = 3) or open (n-1) RYGB after failed vertical banded gastroplasty, and one patient underwent open redo RYGB due to large gastric pouch. Conversion rate from laparoscopy to open surgery was 2.5% (one patient). Mean operative time was 145.83 ± 35.19 min, and hospital stay was 3.36 ± 1.20 days. There was no mortality. Early and late complications occurred in six patients (14.2%). The mean follow-up was 15.83 ± 13.43 months. Mean preoperative body mass index was 45.15 ± 7.95 that decreased to 35.23 ± 6.7, and mean percentage excess weight loss was 41.19 ± 20.22 after RYGB within our follow-up period. RYGB as a revisional bariatric procedure is effective to treat complications of restrictive procedures and to further reduce weight in morbidly obese patients.

Excellent Laparoscopic Gastric Bypass Outcomes Can be Achieved at a Community-Based Training Hospital With Moderate Case Volume

Our objective was to assess laparoscopic gastric bypass outcomes in a moderate case volume setting. Laparoscopic gastric bypass remains one of the most advanced laparoscopic procedures currently performed worldwide. The following represents a single institutional series from a community hospital-based training program with a minimally invasive bariatric surgical program. Data from all patients undergoing laparoscopic gastric bypass since the inception of the program were entered into a prospective database. Measured outcomes included length of operation, length of stay, major and minor complications, and percentage excess weight loss. Results were compared with published outcomes from a review of the literature encompassing more than 3400 cases using chi and Fisher exact tests. Between September 2001 and October 2008, 700 consecutive patients underwent laparoscopic gastric bypass. The mean age was 43.1 +/- 9.5 years, and 83% were female. The mean initial weight was 135.5 +/- 22.4 kg. The initial body mass index was 47.9 +/- 6 kg/m. The mean length of stay was 2.2 +/- 0.9 days. The length of operation was 147.8 +/- 31.8 minutes. The mean percent excess weight loss at 1-year postoperative was 72.4%. There were no mortalities. Compared with the literature, we achieved a lower rate of anastomotic leak (0.3% vs. 2%, P = 0.001) and stomal stenosis (1% vs. 4.7%, P = 0.001). Excellent outcomes following laparoscopic gastric bypass can be achieved in a community hospital-based program with moderate case volume. Reimbursement decisions should take into consideration a program's actual outcomes rather than volume.

Predictive Factors of Weight Loss 1 Year after Laparoscopic Gastric Bypass in Obese Patients

Substantial weight loss is achieved in majority of severely obese subjects undergoing laparoscopic gastric bypass (LGBP) but some fail to obtain expected results. Our aim was to identify preoperative factors that could influence weight loss (WL) 1 year after LGBP. We studied the predictive value of clinical, biological, and dietary preoperative factors on weight loss in obese patients referred for LGBP. WL was assessed according to mean absolute weight loss (AWL) and mean percent excess weight loss (%EWL) 1 year after LGBP. One hundred twenty-three subjects were included (112 women, age 42 ± 10 years; weight 127 ± 23 kg; BMI 47 ± 8 kg/m(2)). Mean AWL was 39.4 ± 10.5 kg at 1 year, corresponding to a mean %EWL of 70.5 ± 21.2%. AWL was positively correlated with initial weight, BMI, and energy intake and negatively with age, female sex, and treatment for hypertension and diabetes. %EWL was negatively correlated with initial weight, BMI, and positively correlated with triglycerides and ferritinemia. In multivariate analysis, %EWL was negatively correlated only with initial BMI (p < 0.001). AWL was positively correlated with initial BMI and male sex (both p < 0.001), and negatively correlated with protein intake (p = 0.039) and treatment for diabetes (p = 0.021), but not with biomarkers of diabetes and insulin resistance. Initial BMI appears to be a strong determinant of individual WL, but predictive factors differ when WL was expressed as %EWL or AWL. The treatment of diabetes rather than diabetes itself appears to affect WL.

Efficacy, Safety, and Tolerance of Two Types of Intragastric Balloons Placed in Obese Subjects: A Double-Blind Comparative Study

The intragastric balloon is a temporary treatment for obese patients. Fluid-filled devices have shown efficacy and safety, and are widely used. Recently, although there are no comparative studies between them, an air-filled balloon, Heliosphere® bag, has been proposed. Prospective, double-blind study in 33 patients with morbid and type 2 obesity: 23 female, 43.9±10 years, 120.3±17 kg, and body mass index (BMI) of 44.2±5 kg/m2, placing 18 gastric balloons filled with 960 cm3 of air (Heliosphere® bag) or 15 balloons filled with 700 ml of saline (Bioenterics-BIB®). Both balloons were placed with conscious sedation and removed under general anesthesia 6 months later. Intravenous drugs were given to control symptoms for 48 h. Patients were sent home on a 1000-kcal diet, multivitamin supplements, and oral proton pump inhibitors, and were followed monthly. Complications, symptoms, weight, and quality of life evaluated by the Gastrointestinal Quality of Life Index (GIQLI) scale were recorded. At 6 months, mean weight loss (12.8±8 vs 14.1±8 kg), BMI loss (4.6±3 vs 5.5±3 kg/m2) and percent excess weight loss (27±16 vs.30.2±17) showed no significant differences between both groups. At removal, two Heliosphere® bags were not found in the stomach, and four patients required extraction of the balloon by rigid esophagoscopy or surgery (p=0.02). Tolerance was good in both groups, but early removal occurred in three BIB® (20%) due to vomits and dehydration. The GIQLI total scores remained unchanged. Both balloons achieve a significant weight loss with good tolerance in obese patients. Nevertheless, Heliosphere® bag has severe technical problems that need to be solved before recommending it.

Laparoscopic adjustable gastric banding via pars flaccida versus perigastric positioning: technique, complications, and results in 2,549 patients

Retrospective multicenter analysis of the results of two different approaches for band positioning: perigastric and pars flaccida. Data were collected from the database of the Italian Group for LapBand (GILB). Patients operated from January 2001 to December 2004 were selected according to criteria of case-control studies to compare two different band positioning techniques: perigastric (PG group) and pars flaccida (PF group). Demographics, laparotomic conversion, postoperative complications, and weight loss parameters were considered. Data are expressed as mean +/- standard deviation. 2,549 patients underwent the LapBand System procedure [age: 40 +/- 11.7 years; sex: 2,130 female, 419 male; body mass index (BMI): 46.4 +/- 6.9 kg/m(2); excess weight (EW): 60.1 +/- 23.6 kg; %EW: 90.1 +/- 32.4]. During this period 1,343/2,549 (52.7%) were operated via the pars flaccida (PF group) and 1,206/2,549 (47.3%) via the perigastric approach (PG group). Demographics for both groups were similar. Thirty-day mortality was absent in both groups. Operative time was significantly longer in the PG group (80 +/- 20 min versus 60 +/- 40 min; p < 0.05). Hospital stay was similar in the two groups (2 +/- 2 days). Laparotomic conversion was significantly higher in the PG group (6 versus 2 patients; p < 0.001). Overall postoperative complication rate was 172/2,549 (6.7%) and was linked to gastric pouch dilation/slippage (67/172), intragastric migration/erosion (17/172), and tube/port failure (88/172). Gastric pouch dilation and intragastric migration were significantly more frequent in the PG group: 47 versus 20 (p < 0.001) and 12 versus 5 (p < 0.001), respectively. Patients eligible for minimum 3-year follow-up were 1,118/1,206 (PG group) and 1,079/1,343 (PF group). Mean BMI was 33.8 +/- 12.1 kg/m(2) (PG group) and 32.4 +/- 11.7 kg/m(2) (PF group) (p = ns), and mean percentage excess weight loss (%EWL) was 47.2 +/- 25.4 and 48.9 +/- 13.2 in PG and PF groups, respectively (p = ns). Significant improvement in LapBand System results with regard to laparotomic conversion and postoperative complication rate, with similar weight loss results, was observed in the pars flaccida group.

Prospective single-site case series utilizing an endolumenal tissue anchoring system for revision of post-RYGB stomal and pouch dilatation

Interventional therapy for weight regain after gastric bypass surgery has been tempered by higher complications associated with revisional surgery. Endolumenal reduction of post-bypass stomal and pouch dilatation offers the promise of a safer approach. Questions still remain regarding safety and efficacy with these procedures. We report intra- and postoperative results to date utilizing an endolumenal suturing platform for this patient subset. Patients who had regained significant weight 2+ years after Roux-en-Y gastric bypass (RYGB) after losing ≥ 50% of excess body weight (EBW) post RYGB underwent endolumenal stomal and pouch reduction if they endoscopically displayed post-bypass stomal and/or pouch dilatation. The platform was utilized to endolumenally reduce stoma size by creating circumferential folds with a tissue anchoring system. Anchors were also utilized to approximate gastric pouch tissue. Information regarding patient baseline status and data on procedural safety, intraoperative performance, postoperative weight loss, and anchor durability were recorded to date with use of this system. In 20/21 subjects we were able to successfully place anchors (one patient had occult G-G fistula which impaired visualization). Weight regain post RYGB averaged 59 lbs (N = 20). Stomal diameter was reduced on average by 53%, with pouch reduction averaging 41%. The number of anchors placed on average per case was 5.3. Operating room (OR) time averaged 91 min. There were no significant complications. Three- and 12-month esophagogastroduodenoscopy (EGD) results revealed preservation of most of the intraoperative stoma and pouch reduction, and presence of fibrotic tissue folds with continued presence of anchors at their original locations. Mean percentage excess weight loss (%EWL) at 6 months was 18% to date (N = 18). Mean weight loss at 6 months was 17.3 ± 15 lbs. Clinical study of this endolumenal tissue approximation system has shown intraoperative safety and efficacy in reducing stoma and pouch dilatation post RYGB. Follow-up anchor durability to date is encouraging. Continuing weight loss is being tracked through ongoing endoscopic and clinical follow-up.

Sleeve Gastrectomy as Sole and Definitive Bariatric Procedure: 5-Year Results for Weight Loss and Ghrelin

Due to excellent efficacy for weight loss in the short-term follow-up, sleeve gastrectomy (SG) has gained enormous popularity as bariatric procedure, not only as first step in high-risk or super-obese patients but mainly as a sole and definitive operation in morbidly obese. In contrast to a large number of short and intermediate-term results, no series of SG with a follow-up of 5 years or more has been published so far. We report on the weight loss results of our first consecutive 26 patients with a complete follow-up of 5 years. Furthermore in a subgroup of 12 patients, plasma ghrelin levels were measured preoperatively, and up to 5 years following SG. Weight loss defined as mean percent excess weight loss (%EWL) was found as 57.5 +/- 4.5, 60.3 +/- 5.0, 60.0 +/- 5.7, 58.4 +/- 5.4, and 55.0 +/- 6.8 (not converted, n = 21) for the first 5 years. Weight regain of more than 10 kg from nadir was observed in five (19.2%) of the 26 patients. Four of the patients (15.4%) were converted to gastric bypass due to severe reflux (n = 1, 3.8%) and weight loss failure (n = 3, 11.5%). A total of eight patients (30.8%) were at chronic need for proton pump inhibitor medication due to severe reflux. Plasma ghrelin levels were reduced from 593 +/- 52 to 219 +/- 23 pg/ml 12 months postoperatively, with a slightly, non-significant increase toward the 5-years values of mean 257 +/- 23 pg/ml. At 5-year follow-up, a mean EWL of 55.0 +/- 6.8% was achieved, indicating that SG leads to stable weight loss. Beside significant weight regain, severe reflux might necessitate conversion to gastric bypass or duodenal switch. After an immediate reduction postoperatively, plasma ghrelin levels remained low for the first 5 years postoperatively.

Initial experience in laparoscopic sleeve gastrectomy for Japanese morbid obesity

AbstractIntroduction: We evaluated the safety and efficacy of laparoscopic sleeve gastrectomy (LSG) in Japanese patients with morbid obesity.Materials and Methods: Between June 2006 and March 2009, seven morbidly obese Japanese patients (four women, three men; mean age 36±12 years; mean body mass index (BMI) 51±3 kg/m2) underwent LSG at our institute. The inclusion criteria were morbid obesity (BMI&gt;35 kg/m2), the presence of obesity‐related disorders, and failure to lose weight while using other medical therapies for at least 6 months. The criteria also included contraindications for laparoscopic adjustable gastric banding or super‐obesity (BMI&gt;50 kg/m2). LSG was carried out using endoscopic linear staplers from the greater curvature of the antrum 6–7 cm proximal to the pyloric ring to the angle of His alongside a 32‐Fr endoscope or a 45‐Fr overtube of the endoscope.Results: In all of the patients, LSG was successfully performed without open conversion. There were no serious postoperative complications and there was no mortality. The mean weight loss and percent excess weight loss after LSG were 33±8 kg and 47±16% at 6 months, and then 44±16 kg and 63±30% at 12 months. Due to the weight loss, the resolution and improvement rates of comorbidities in the five patients followed up for &gt;3 months were 100% and 100% in type 2 diabetes, 67% and 100% in hypertension, 60% and 100% in dyslipidemia, and 100% and 100% in metabolic syndrome.Discussion: Although further long‐term studies are necessary with regard to weight maintenance, LSG is a feasible and safe treatment for Japanese patients with morbid obesity.

Calcium, Parathormone, and Vitamin D Abnormalities among Roux-en-Y Gastric Bypass Patients

Background: Malabsorption of vitamin D and calcium is a known side effect of laparoscopic gastric bypass (LGB). Our objective was to identify the prevalence of abnormalities in calcium, parathormone (PTH), and 25-OH vitamin D levels in patients undergoing LGB, and the correlation of reported compliance with supplementation, and seasonal variation on vitamin D levels. Methods: Patients undergoing LGB from September 2003 through June 2004 were included. Calcium and PTH levels were obtained preoperatively. At 1 year postoperatively, calcium, PTH, and vitamin D levels were obtained. Laboratory values were classified as low, normal, or high, based on standard reference ranges. Results were analyzed using the exact binomial test. Results: One-year follow-up laboratory data were available for 70 patients: 10 males and 60 females with a mean age of 44.7 years. The mean preoperative body mass index was 47.4 kg/m2. Mean percent excess weight loss at 1 year was 73.4%. Nine patients (14.3%) had elevated PTH levels preoperatively, and seven patients (10.3%) had elevated PTH postoperatively (p ≤ 0.001). The incidence of low 25-OH vitamin D levels postoperatively was 40.4%. Conclusions: A significant percentage of patients undergoing LGB present with an abnormally high PTH level. Abnormally low vitamin D levels are quite prevalent 1 year after LGB, despite normal serum calcium levels. The month of surgery (summer vs. winter) did not have an impact on PTH, calcium, or vitamin D levels. Patients' self-reported compliance or noncompliance with recommended supplementation did not correlate with their vitamin D levels.