Proximal Gastric Pouch Research Articles

Laparoscopic sleeve gastrectomy with ileal transposition (SGIT): A new surgical procedure as effective as gastric bypass for weight control in a porcine model

Bariatric surgery has evolved into multiple forms in the last decades, combining food restriction and malabsorption. The aim of this study was to develop a new technique based on food restriction and early stimulation of the distal gut, thus maintaining the alimentary tract continuity. Thirty-two Yorkshire pigs, weight 22.2 +/- 5.4 kg (mean +/- SD) were randomly assigned to four laparoscopic procedures: ileal transposition (IT, n = 8); sleeve gastrectomy with ileal transposition (SGIT, n = 8); Roux-en-Y gastric bypass (GBP, n = 8); sham operation (SHAM, n = 8). Firing 45-mm linear staplers over a 60-F bougie, resecting the greater curvature and fundus, constituted a sleeve gastrectomy. Ileal transposition was performed by isolating a 100-cm ileal segment proximal to the ileocecal valve and by dividing the proximal jejunum 15 cm distal to the ligament of Treitz and performing re-anastomosis. Gastric bypass consisted of creating a proximal gastric pouch and a 300 cm alimentary limb. Sham operation was performed by bowel transections and re-anastomosis in the ileum and proximal jejunum together with gastrotomy and closure. Animals were evaluated weekly for weight increase and food intake. We performed a logistic regression analysis to compare weight progression curves, and analysis of variance (ANOVA) and Bonferroni (Dunn) tests to detect differences in weight and food intake. We observed significant differences in mean weight after 18 weeks between SGIT (30.9 +/- 13.4 kg) and SHAM (72.5 +/- 10.7 kg) (p = 0.0002), and GBP (28.6 +/- 2.5 kg) and SHAM (p = 0.0001), and IT (56.1 +/- 13.4 kg) and SHAM (p = 0.0081). No differences were observed between RYGB and SGIT. We also observed significant differences in food intake (grams per day) in the third month between SGIT (1668 +/- 677 g) versus SHAM (3252 +/- 476 g) (p = 0.0006), and GBP (2011 +/- 565 g) versus SHAM (p = 0.039). No differences were observed in food intake between SGIT and GBP. SGIT proved to be as effective in the short term as GBP on weight progression with no bypass of the proximal gut.

Comparison of size of proximal gastric pouch and short-term weight loss following routine upper gastrointestinal contrast study after laparoscopic Roux-en-Y gastric bypass

The authors investigated whether there is any correlation between gastric pouch size measured by routine upper gastrointestinal contrast study (UGI) after laparoscopic Roux-en-Y gastric bypass (LRYGBP) and short-term weight loss. The study group consisted of 82 patients (66F, 16M) who underwent LRYGBP. Body mass index before surgery ranged from 35.4 to 71.7 kg/m2, with a mean of 47.4 kg/m2. UGI was performed 1 day after LRYGBP in all patients. Proximal gastric pouch size was estimated by multiplying maximal transverse and longitudinal diameters on AP spot image or film. Percent excess weight loss (%EWL) obtained at 3, 6, 12 and 24 months after surgery was used as an indicator of short-term results. According to the presence of contrast passage through the gastrojejunostomy, each patient was classified into 2 groups: Group A, negative; Group B, positive. There was no correlation between proximal gastric pouch size and %EWL at any point of time (P>0.05). The correlation coefficients calculated for 3, 6, 12 and 24 months after surgery were 0.038, 0.110, 0.015 and 0.042, respectively (Pearson correlation test). The gastric pouch size of Group A was larger than that of Group B (Student t-test, P<0.001). There was no difference in %EWL between Groups A and B at 3 and 6 months after surgery (P>0.05). Pouch size area, measured by routine UGI study on the first postoperative day, does not influence short-term postoperative weight loss.

Comparison of size of proximal gastric pouch and short-term weight loss following routine upper gastrointestinal contrast study after laparoscopic Roux-en-Y gastric bypass

Comparison of size of proximal gastric pouch and short-term weight loss following routine upper gastrointestinal contrast study after laparoscopic Roux-en-Y gastric bypass

Intracolonic tubing migration: an unusual complication of the silastic adjustable gastric band (LapBand)

Obesity is a condition of multifactorial etiology with high personal and societal costs. In general, it has proved refractory to medical management. For decades, surgical procedures have been available for the treatment of obesity. However, recently, their popularity has increased. One of the currently favored restrictive techniques is the laparoscopic adjustable gastric band system in which an adjustable, inflatable band is placed around the gastric cardia, creating a small proximal gastric pouch.

Prospective randomized trial of banded versus nonbanded gastric bypass for the super obese: early results

Banded gastric bypass has been reported to result in superior weight loss compared with standard nonbanded gastric bypass. However, an adequate comparison of these procedures has not yet been reported. A total of 90 patients were enrolled in this prospective randomized double-blind trial comparing banded and nonbanded open gastric bypass for the treatment of super obesity. The banding technique involved placement of a 1.5 x 5.5-cm polypropylene band around the proximal gastric pouch of a standard gastric bypass procedure using the technique of Capella. Chi-square testing and analysis of variance were performed to find any differences in patient characteristics (gender, age, and initial body mass index), percentage of excess weight lost at 6, 12, 24, and 36 months postoperatively, improvement or resolution of co-morbidities, and complications in the banded versus nonbanded gastric bypass groups. As expected, no differences were present in the patient characteristics or incidence of co-morbidities between the banded (n = 46) and nonbanded (n = 44) groups. The body mass index, percentage of women, and mean age was 59.5 and 56.5 kg/m2, 64% and 73.8% (P = .09), and 40.6 +/- 7.4 and 42.6 +/- 7.2 years for the banded and nonbanded groups, respectively; all differences were nonsignificant. No significant differences were found in the resolution of co-morbidities. No significant difference was present in the percentage of excess weight loss at 6, 12, and 24 months (43.1% versus 24.7%, 64.0% versus 57.4%, and 64.2% versus 57.2%, respectively) postoperatively; however, the banded patients had achieved a significantly greater percentage of excess weight loss at 36 months (73.4% versus 57.7%; P <.05). The incidence of intolerance to meat and bread was greater in the banded patients. The overall number of complications was 12 (26%) in the banded and 13 (29.5%) in the nonbanded group, a nonsignficant difference. No band erosions had occurred at the last follow-up visit, and no patients in either group died. These results suggest that although the initial weight loss was not significantly different between the 2 groups, the banded patients continued to lose weight for < or = 3 years. The polypropylene band appeared to be well tolerated. We plan longer follow-up to confirm the possibility of additional weight loss and the prevention of weight regain in the banded group, as well as to document any long-term band complications.

V5

Despite the great success and popularity of adjustable gastric banding (AGB) in Europe, some concerns exist about the high rate of long-term complications. The most frequent of these complications is gastric pouch dilatation. Patients who don’t feel a sense of fullness may fill the proximal gastric pouch with a large amount of food causing an enlargement of the stomach above the band. The onset can be chronic or acute and in many cases requires reoperation.

Impact of Gastric Bypass Surgery on Gut Hormones and Glucose Homeostasis in Type 2 Diabetes

Gastric bypass surgery (GBP) for obesity, by constructing an isolated ∼30-ml proximal gastric pouch connected to a 75-cm limb of proximal jejunum, bypassing &amp;gt;90% of the stomach, the pylorus, and the duodenum, cures type 2 diabetes in &amp;gt;80% of cases. We review alterations in gastrointestinal peptide release after GBP that affect glucose disposal. We focus on ghrelin and the incretins glucose-dependent insulinotropic polypeptide, glucagon-like peptide 1, and peptide YY as the most likely candidates for increasing insulin sensitivity after these operations, even before substantial weight loss has occurred. Although we have limited our review to only four gastrointestinal peptides, others may be involved, as are adipocyte-derived molecules such as leptin and adiponectin, and substrate receptor interactions in target tissues including the brain.

Pouch diverticula after vertical-banded gastroplasty

Diverticula of the proximal gastric pouch are rare after vertical-banded gastroplasty (VBG) for morbid obesity. We report the radiographic findings observed in a series of 12 patients with pouch diverticula. Lesions were found along the posteromedial wall of the proximal gastric pouch and ranged in size from 10 to 25 mm. Only two patients were symptomatic at the time of diagnosis; in most cases, diverticula were discovered during studies performed as part of the standard follow-up protocol. Diverticula were followed up in 7/12 cases, and four showed slight enlargement over a period ranging from 14 to 53 months. The presence of diverticula was not correlated with symptoms, postoperative weight loss, or clinical history, and no differences in long-term complications were demonstrated between VBG patients with diverticula and those without them. We do not believe these lesions to be clinically important; at present, our patients are no longer followed up for this problem and undergo diagnostic examinations only if and when they develop symptoms.

V4: Basket band: A new adjustable gastric band developed to avoid proximal gastric pouch dilatation. Preliminary series

Adjustable Gastric Banding (AGB) is the most popular bariatric procedure in Europe. The main complication of the procedure is gastric pouch dilatation: it affects quality of life and in case of acute onset, it requires emergency re-operation. For this reason we developed a new adjustable gastric band called Basket Band (BB). The band is a regular one with a soft silicone mesh above it, thought to envelope the proximal gastric pouch to prevent it from enlargement.

Endoscopic Diagnosis and Treatment of Late Complications of Gastric Bandage

Background: Gastric bandage became a standard surgical procedure for treatment of morbid obesity. However, up to 15% of patients develop complications several months or even years after operation. Whenever possible, endoscopic diagnosis and treatment should be the method of choice. Methods: Late complications of gastric bandage include dilatation of proximal gastric pouch, slippage of the pouch, migration of the bandage through the gastric wall into the stomach, gastric ulcers, infections of bandage system, or its mechanical damage. We performed a retrospective assessment of late complications after gastric bandage, and evaluation of utility of upper endoscopy for making correct diagnosis and treatment of such complications. Results: Between January 1998 and October 2005, 32 patients (i.e. 3.9% out of 811 patients operated on in our center) with gastric bandage were sent to our endoscopic unit to perform upper endoscopy due to their acute or chronic complaints. Most of them had nauzea and vomiting, remaining had epigastric pain after meal or without association with meal. All of them underwent upper endoscopy with following findings: 24 pts had dilatation and/or slippage of the pouch, 3 pts were diagnosed with complete or partial migration of the bandage into the stomach, and 1 had a large bezoar formed by coconut. Remaining 4 pts had normal findings. Among patients with dilatation or slippage, in 19 out of 20 cases, the endoscopic examination of entire stomach (including distal part below the bandage) was possible. All cases were diagnosed correctly by endoscopy alone, in 3 patients the diagnosis of the dilatation or slippage was misdiagnosed by previous X-ray examination. Patients with migrating bandage were treated by combination of upper endoscopy plus laparoscopy (1 case), and by endoscopy alone (2 cases), where the migrated bandage was cut by endoscopical scissors. Patient with coconut bezoar in gastric pouch was treated by upper endoscopy followed by surgical removing of the bandage. Conclusions: Upper endoscopy is a usefull method for diagnosing most complications that occur after gastric bandage placement. Some complications my even be treated endoscopically or with endoscopic assistance.

Endoscopic and Histologic Findings in the Gastric Pouch and the Roux Limb after Gastric Bypass

Despite the large number of gastric bypasses performed for morbid obesity, very little is known about the endoscopic and histologic aspects of the gastric pouch and the Roux-limb late after surgery. We performed prospective routine endoscopic and histologic studies of the pouch and Roux-limb 2 years after gastric bypass. The present study includes 227 patients submitted to resectional gastric bypass and followed for a mean of 27 months after surgery. Mean BMI before bypass was 44 kg/m2. In all patients, upper endoscopy of the pouch and of the jejunal limb was performed, taking 3 biopsy samples of the gastric pouch in 171 patients and 2 samples of the jejunum in 40 patients. Macroscopic appearance of the gastric pouch was normal in 99% of the patients and of the jejunal limb in 100%. Histologic analysis revealed normal fundic mucosa in 56%. Chronic active gastritis was the most frequent abnormal histologic finding. 7 patients (4.1%) showed intestinal metaplasia. H. pylori infection was present in the gastric pouch in 31% of the patients. The proximal gastric pouch after gastric bypass is endoscopically normal in 99% of patients 2 years after surgery, while the Roux-limb is normal in 100%. Histologic analysis of gastric mucosa revealed normal fundic mucosa in 56%. There are some chronic histologic changes, even intestinal metaplasia, whose behavior at late follow-up is not yet known. H. pylori is present in nearly (1/3) of the patients.

Adjustable Gastric Banding as a Revisional Bariatric Procedure after Failed Gastric Bypass

Inadequate weight loss after proximal gastric bypass presents a clinical challenge to bariatric surgeons. Pouch size, stoma size and limb length are the variables that can be surgically altered. Aside from conversion to distal bypass, which may have significant negative nutritional sequelae, revisional surgery for this group of patients has not often been reported. The addition of adjustable silicone gastric banding (ASGB) to Roux-en-Y gastric bypass (RYGBP) may be a useful revision strategy because it has potential safety benefits over other revisional approaches. We report on 8 patients who presented with inadequate weight loss or significant weight regain after proximal gastric bypass. All patients underwent revision with the placement of an ASGB around the proximal gastric pouch. Bands were adjusted at 6 weeks postoperatively and beyond as needed. Complications and weight loss at the most recent follow-up visit were evaluated. Mean age and body mass index (BMI) at the time of revision were 39 +/- 9.9 years and 44.0 +/- 4.5 kg/m2 respectively. No patients were lost to follow-up, and they lost an average of 38.1 +/- 10.4% and 44.0 +/- 36.3% of excess weight and 49.1 +/- 20.9% and 52.0 +/- 46.0% of excess BMI in 12 and 24 months respectively. Patients lost an average of 62.0 +/- 20.5% of excess weight from the combined surgeries in 67 (48-84) months. The only complication was the development of a seroma overlying the area of the port adjustment in one patient. There have been no erosions or band slippages to date. These results indicate that the addition of an ASGB causes significant weight loss in patients with poor weight loss outcome after RYGBP. The fact that no anastomosis or change in absorption is required may make this an attractive revisional strategy. Long- term evaluation in a larger population is warranted.

Laparoscopic Pouch Resizing and Redo of Gastro-jejunal Anastomosis for Pouch Dilatation following Gastric Bypass

With a dramatically increasing number of bariatric operations performed world-wide in the recent years, more late complications have been noticed. Proximal gastric pouch dilatation is a known late complication after laparoscopic or open restrictive surgery for morbid obesity. In the present paper, we report our experience with laparoscopic re-operation of enlarged gastric pouches after laparoscopic gastric bypass, with emphasis on technique and outcome. Data were retrieved from a prospective database of 334 patients who underwent a laparoscopic gastric bypass operation at the University Hospital of Zurich from July 2000 to December 2004. Five laparoscopic revisions for pouch dilatation after primary bypass were performed. 3 female and 2 male patients with median age 40 years (range 32-55) underwent a laparoscopic pouch resizing. At the time of the re-operation, the median BMI was 32.0 kg/m(2) (range 28.4-48.4). All procedures were performed laparoscopically with no conversion to open surgery. The median operating-time was 110 minutes (95-120). The median hospital stay was 6 days (range 5-14). The median BMI in the follow-up of 12 months (9-14) was 28.0 kg/m(2) (25.5-45.8). Diabetes mellitus improved in 4 cases during follow-up. Laparoscopic pouch resizing with redo of the gastro-jejunal anastomosis was feasible, safe and effective in this small series. It led to further weight loss and improved symptoms of poor pouch emptying.

The Proximal Gastric Pouch Invariably Contains Acid-Producing Parietal Cells in Roux-en-Y Gastric Bypass

Roux-en-Y gastric bypass (RYGBP) is well tolerated and effective in ameliorating diseases common to morbidly obese patients. A potential drawback, however, is the risk for stomal ulcers, probably due to acid and peptic digestion of the mucosa in the proximal Roux limb. In 23 RYGBP patients (mean BMI 45 kg/m(2), age 39 years), the gastro-jejunostomy was performed by circular stapler and the gastric suture ring retrieved for histological examination. 13 consecutive patients received our standard totally transected 4 x 3 cm proximal gastric pouch. The anvil was passed transgastricly and reference biopsies were taken from the gastrotomy in the corpus of the stomach. In the last 10 patients, the pouch size was reduced to 2 x 3 cm by a modified surgical technique. All suture rings from the standard pouches consisted of corpus-fundus mucosa with a large amount of parietal cells, histologically identical to the reference biopsies from the gastrotomy. Also, the 10 suture rings from the modified small pouches contained corpus-fundus mucosa. In 5 of these samples, cardiac mucosa was found, but only in a small segment (6 mm). In addition, 3 patients had esophageal epithelium in the suture ring. The proximal pouch invariably contains acid-producing parietal cells. In order to reduce acid production and, hence, the risk of stomal ulcers, the pouch has to be made as small as possible.

Vagal afferent discharge in sleeve gastrectomy

Purpose: The vagus autonomic reflexes elicited by stomach dilation and presence of food may control satiety. Sleeve gastrectomy effectively reduces excess weight; however, the physiology remains unclear. We analyzed the activity of the vagal nerve in response to stomach distension after creation of a proximal gastric pouch and sleeve gastrectomy.

Transoral Obesity Surgery: Endoluminal Gastroplasty with an Endoscopic Suture Device

Surgical creation of a small gastric pouch with a restricted outlet is a well-established option for the treatment of morbid obesity. This report describes initial experience with endoscopic transoral stomach partition using a newly designed suturing apparatus. A fresh porcine stomach was placed in the Erlangen model. A prototype suture device, incorporating a curved needle and an intracorporeal tightening mechanism, was used in this procedure. A long fishing line was first introduced into the stomach, with the two ends left outside. The suturing device, premounted outside a standard gastroscope, was inserted into the stomach and delivered several stitches attaching the fishing line to both the anterior and posterior walls along the line for the stomach to be partitioned. Five throws of half-hitches were tied onto the fishing line extracorporeally and separately pushed into place, creating a gastric pouch just below the esophagogastric junction. A flexible sheath of 8 cm long was then put on one side of the fishing line and pushed into the stomach. Additional extracorporeal knots were tied on the fishing line, forming a restrictive ring at the outlet of the pouch. The ring was then anchored to the stomach wall with similar endosutures. The proximal gastric pouch, with an estimated volume of approximately 100 ml, was successfully created with a restrictive band at its outlet. All of the stitches were securely sutured, with consistent penetration of the muscular layer of the stomach wall. In a bench model, it is technically possible to accomplish transoral gastroplasty endoscopically with an intraluminal suturing device. Further live animal studies will be needed in order to confirm the efficacy and safety of this procedure before clinical application.

Intragastric Band Erosion After Laparoscopic Adjustable Gastric Banding for Morbid Obesity: Imaging Characteristics of an Underreported Complication

Our purpose was to describe the imaging findings of intragastric band erosion, an underreported complication after laparoscopic adjustable gastric banding for the treatment of morbid obesity. In this long-term complication, the gastric band fastened around the upper stomach to create a small proximal gastric pouch gradually erodes into the stomach wall and can extend into the gastric lumen. We present three cases of patients with band erosion in whom findings on an upper gastrointestinal series and CT established the diagnosis. Diagnosis of intragastric band erosion after gastric banding is usually made with endoscopy. However, the radiologic appearance of band erosion when visualized on an upper gastrointestinal series is pathognomonic and allows initial imaging diagnosis. In patients with extraluminal air or prosthesis infection, CT findings also are suggestive of this postoperative complication.

Laparoscopic Conversion of Laparoscopic Gastric Banding to Roux-en-Y Gastric Bypass: a Review of 70 Patients

The feasibility and outcomes of conversion of laparoscopic adjustable gastric banding (LAGB) to laparoscopic Roux-en-Y gastric bypass (LRYGBP) was evaluated. From November 2000 to March 2004, all patients who underwent laparoscopic conversion of LAGB to LRYGBP were retrospectively analyzed. The procedure included adhesiolysis, resection of the previous band, creation of an isolated gastric pouch, 100-cm Roux-limb, side-to-side jejuno-jejunostomy, and end-to-end gastro-jejunostomy. 70 patients (58 female, mean age 41) with a median BMI of 45+/-11 (27-81) underwent attempted laparoscopic conversion of LAGB to an RYGBP. Indications for conversion were insufficient weight loss or weight regain after band deflation for gastric pouch dilatation in 34 patients (49%), inadequate weight loss in 17 patients (25%), symptomatic proximal gastric pouch dilatation in 15 patients (20%), intragastric band migration in 3 patients (5%), and psychological band intolerance in 1 patient. 3 of 70 patients (4.3%) had to be converted to a laparotomy because of severe adhesions. Mean operative time was 240+/-40 SD min (210-280). Mean hospital length of stay was 7.2 days. Early complication rate was 14.3% (10/70). Late major complications occurred in 6 patients (8.6%). There was no mortality. Median excess body weight loss was 70+/-20%. 60% of patients achieved a BMI of <33 with mean follow-up 18 months. Laparoscopic conversion of LAGB to RYGBP is a technically challenging procedure that can be safely integrated into a bariatric treatment program with good results. Short-term weight loss is very good.

The effects of gastric surgery on systemic ghrelin levels in the morbidly obese.

Circulating ghrelin, produced primarily in the stomach, is a powerful orexigen. Ghrelin levels are elevated in states of hunger, but rapidly decline postprandially. Early alterations in ghrelin levels in morbidly obese patients undergoing weight reduction surgery may be attributed to gastric partitioning. Thirty-four patients underwent Roux-en-Y gastric bypass with a completely divided gastroplasty to create a 15-mL vertically oriented gastric pouch. Eight other patients underwent other gastric procedures that did not involve complete division of the stomach, including 4 vertical banded gastroplasties and 4 antireflux surgical procedures. Six additional patients undergoing antireflux surgery served as lean control subjects. Plasma samples were obtained before surgery and immediately after surgery. In a substudy, plasma was collected after Roux-en-Y limb formation and after dividing the stomach to identify any changes in plasma ghrelin levels. Tertiary university medical center. Ghrelin levels at different stages of surgical intervention. Mean +/- SEM preoperative and postoperative ghrelin levels in the gastric bypass group were 355 +/- 20 and 246 +/- 13 pg/mL, respectively (P<.001). In the vertical banded gastroplasty group and in all patients undergoing antireflux surgery, ghrelin levels were not significantly changed. Compared with morbidly obese humans, lean controls had significantly higher plasma ghrelin levels at baseline. A divided gastroplasty creating a small proximal gastric pouch results in significant early declines in circulating ghrelin levels that are not observed with other gastric procedures. This may explain, in part, the loss of hunger sensation and rapid weight loss observed following gastric bypass surgery.

Anesthetic Considerations for Bariatric Surgery

According to the National Institutes of Health, obesity is a major health problem with clearly established health implications, including an increased risk for coronary artery disease, hypertension, dyslipidemia, diabetes mellitus, gallbladder disease, degenerative joint disease, obstructive sleep apnea, and socioeconomic and psychosocial impairment (1). The risk of developing one or more of these obesityrelated conditions is based on body mass index (BMI), with 25–30 kg/m 2 being low risk and 40 kg/m 2 being very high risk (2). The prevalence of obesity in the 18- to 29-yr-old group increased from 12% in 1991 to 18.9% in 1999 (3). Bariatric surgery encompasses a variety of surgical weight loss procedures used to treat morbid obesity. Obesity is clinically expressed in terms of BMI or Quetelet’s index (4), which is derived by dividing weight by the square of height to estimate the degree of obesity. Thus, BMI body weight (kg)/height 2 (m 2 ). Morbid obesity is a BMI more than 35 kg/m 2 , and super morbid obesity is BMI more than 55 kg/m 2 . The indications for surgical treatment of severe obesity, as outlined in the 1991 National Institutes of Health Consensus Development Conference Panel, include an absolute BMI more than 40 kg/m 2 or BMI more than 35 kg/m 2 in combination with lifethreatening cardiopulmonary problems or severe diabetes mellitus (1). Patients seeking surgical weight loss must have proven attempts at medically supervised weight loss. Documentation of loss of 5% to 10% excess body weight or weight gain after at least 6 mo of diet modification, exercise, and medical therapy or nonimprovement in comorbid conditions during this period indicates failure. Studies have shown that weight loss of 5%–10% of initial body weight improves glucose intolerance and Type II diabetes, hypertension, and dyslipidemia (5–7). The average expenditure is approximately $7000 per year per patient on weight loss programs and equipment. Unfortunately, long-term weight loss is the exception, and most patients regain weight, sometimes more than they initially lost.