Vascularized bone grafts for scaphoid nonunions

Scaphoid fractures that fail to unite are at risk of developing avascular necrosis and progressive structural collapse, thereby complicating attempts at revision surgical treatment. Vascularized bone grafts have demonstrated utility in promoting consolidation in the treatment of scaphoid nonunions complicated by avascular necrosis. Numerous pedicled and free vascularized grafts have been described with variable, but generally favorable, outcomes. Understanding the indications for different grafts is critical to the successful application of these techniques and grafts in the treatment of challenging scaphoid nonunions.

In silico whole-genome EST analysis reveals 2322 novel microsatellites for the silver-lipped pearl oyster, Pinctada maxima

Molecular stock improvement techniques such as marker assisted selection have great potential in accelerating selective breeding programmes for animal production industries. However, the discovery and application of trait/marker associations usually requires a large number of genome-wide polymorphic loci. Here, we present 2322 unique microsatellites for the silver-lipped pearl oyster, Pinctada maxima, a species of aquaculture importance throughout the Indo-Australian Archipelago for production of the highly valued South Sea pearl. More than 1.2 million Roche 454 expressed sequence tag (EST) reads were screened for microsatellite repeat motifs. A total of 12,604 sequences contained either a di, tri, tetra, penta or hexa microsatellite repeat motif (n ≥ 6), with 6435 of these sequences having sufficient flanking regions for primer development. All identified microsatellites with designed primers were condensed into 2322 unique clusters (i.e., unique loci) of which 360 were shown to be polymorphic based on multiple sequence reads with different repeat motifs. Genotyping of five microsatellite loci demonstrated that in silico evaluation of polymorphism levels was a very useful method for identification of polymorphic loci, with the variation uncovered being a lower bound. Gene Ontology annotations of sequences containing microsatellites suggest that most are derived from a diverse array of unique genes. This EST derived microsatellite database will be a valuable resource for future studies in genetic map construction, diversity analysis, quantitative trait loci analysis, association mapping and marker assisted selection, not only for P. maxima, but also closely related species within the genus Pinctada.

Panel report: best practices for the surgical treatment of obesity

BACKGROUND

Bariatric surgery is a rapidly growing field. Advances in surgical technologies and techniques have raised concerns about patient safety. Bariatric surgeons and programs are under increased scrutiny from regulatory agencies, insurers, and public health officials to provide high quality and safe care for bariatric patients at all phases of care.

METHODS

During the 2009 annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), a panel of experts convened to provide updated information on patient safety and best practices in bariatric surgery. The following article is a summary of this panel presentation.

RESULTS AND CONCLUSIONS

Weight loss surgery is a field that is evolving and adapting to multiple external pressures. Safety concerns along with increasing public scrutiny have led to a systematic approach to defining best practices, creating standards of care, and identifying mechanisms to ensure that patients consistently receive the best and most effective care possible. In many ways, bariatric surgery and multidisciplinary bariatric surgery programs may serve as a model for other programs and surgical specialties in the near future.

The arterial anatomy of the medial femoral condyle and its clinical implications

The success of vascularized bone grafts from the medial femoral condyle in various clinical applications has sparked renewed interest in the microvascular anatomy of this region. This study describes the arterial supply of the distal medial femoral condyle and its implications in harvesting vascularized bone grafts. The location, branching pattern, internal diameter, and distribution of perforators of the descending genicular artery and superior medial genicular artery in 19 fresh cadaveric lower limbs were recorded. The descending genicular artery was present in 89% and the superior medial genicular artery was present in 100% of specimens with average distances proximal to the articular surface of 13.7 cm and 5.2 cm, respectively. The average number of perforating vessels was greatest in the posterior distal quadrant of the condyle. The blood supply of the medial femoral condyle is plentiful and consistent making it a useful source for free vascularized bone grafts.

Sites of M-CSF messenger RNA production in bone marrow trephine biopsy specimens and long term cultures demonstrated by nonisotopic in situ hybridisation

Aim-To develop methods of messenger RNA (mRNA) in situ hybridisation (ISH) for use with routinely processed bone marrow trephine biopsy specimens, decalcified using formic acid, and long term cultures in order to demonstrate sites of synthesis of mRNA encoding monocyte colony stimulating factor (M-CSF).Methods-Biotinylated oligonucleotide probes, directed against target sequences within M-CSF mRNA, were hybridised with sections from bone marrow trephine biopsy specimens and detected using Streptavidin-biotin alkaline phosphatase complex formation. Validation of results included demonstration of total mRNA and unrelated mRNA species in adjacent sections, with appropriate negative controls. Minor technical modifications were required to perform ISH with long term bone marrow cultures.Results-M-CSF mRNA was demonstrated successfully in trephine biopsy specimens and long term cultures. Biopsy specimens varied in their requirement for predigestion with proteinase K and in the strength of the final reaction product, presumably due to variation in fixation. M-CSF mRNA was present in myelocytes and promonocytes. No stromal production of M-CSF mRNA was detected in biopsy specimens. ISH using long term bone marrow cultures confirmed production of M-CSF mRNA by developing monocytes and macrophages. Weak M-CSF mRNA expression was also seen in stromal fibroblasts.Conclusions-ISH can be performed successfully with formic acid decalcified bone marrow trephine biopsy specimens and long term cultures. The presence of M-CSF mRNA in myelomonocytic cells suggests that an autocrine mechanism contributes to monocyte differentiation. The absence of detectable M-CSF mRNA in biopsy stroma and its presence in stromal fibroblasts within bone marrow cultures probably reflects reduced sensitivity of ISH following tissue fixation and processing.

Zetos: a culture loading system for trabecular bone. Investigation of different loading signal intensities on bovine bone cylinders

The objective of this investigation was to test the effects of different intensities (1000, 1500, 2000, 3000, and 4000 microstrain) of a physiological loading signal (jumping) on trabecular bone stiffness and osteoid thickness using the ZETOS culture and loading system. Fourty eight bovine bone samples were randomised equally across 6 groups: 5 loading groups and 1 control group. The bone samples were cultured for 26 days (DMEM high glucose medium) and subjected to mechanical stress on 23 days. The stiffness of the samples was determined each day before loading in the loading groups and every 3rd day in the control group. The stiffness measurements in the loaded groups were significantly higher than in the control group. The degree of stiffness increased continuously throughout the observation period in the 1500, 2000, and 3000 microstrain groups. Maximum stiffness was achieved in the 4000 microstrain after a very short time (8th loading day) and then remained constant to the end of the investigation. The osteoid thickness in this group was, however, not higher than in the 2000 and 3000 microstrain groups. The 2000 microstrain group showed the highest proportion of newly formed osteoid. The amounts of osteoid deposited in the 2000, 3000 and 4000 microstrain groups were significantly greater than in the control group. Moreover, a correlation between increasing intensity of the signal and increase in osteoid deposition was observed. Histological investigations were conducted on non-decalcified bone and showed a well-preserved trabecular architecture and cell morphology.

Expression of glial cell-derived neurotrophic factor and its receptor in the stem-cell-containing human limbal epithelium

AIM

To evaluate the expression pattern of glial cell line-derived neurotrophic factor (GDNF) with its receptors GDNF family receptor alpha-1 (GFR alpha-1) and Ret in the human corneal and limbal tissues, as well as in the primary human limbal epithelial cultures (PHLEC).

METHODS

Expression of GDNF and its receptors, and the co-localisation with stem cell associated and differentiation markers were evaluated by immunofluorescent staining, western blot analysis and real-time PCR in the fresh human corneoscleral tissues, as well as in the PHLEC. Single cell colony-forming and wound-healing assays were also evaluated in PHLEC.

RESULTS

GDNF and GFR alpha-1 were found to be expressed by a subset of basal cells and co-localised with ATP-binding cassette, subfamily G (WHITE), member 2 (ABCG2) and p63, but not with cytokeratin 3 in the human limbal basal epithelium. In PHLEC, they were expressed by a small population of cells in the less differentiated stage. The GDNF and GFR alpha-1-positive subpopulations were enriched for the expression of ABCG2 and p63 (p<0.01). Recombinant human GDNF promoted the proliferation and wound healing of epithelial cells in the PHLEC. In contrast, Ret was abundantly located in the human corneal epithelium except for the basal cells of the limbal epithelium.

CONCLUSION

These findings indicate that GDNF and GFR alpha-1 may represent a property for the phenotype of human corneal epithelial precursor cells. GDNF may signal independently of Ret through GFR alpha-1 in the stem cell-containing limbal epithelium.

Patients with neuroglycopenia after gastric bypass surgery have exaggerated incretin and insulin secretory responses to a mixed meal

CONTEXT AND OBJECTIVE

Hyperinsulinemic hypoglycemia is newly recognized as a rare but important complication after Roux-en-Y gastric bypass (GB). The etiology of the syndrome and metabolic characteristics remain incompletely understood. Recent studies suggest that levels of incretin hormones are increased after GB and may promote excessive beta-cell function and/or growth.

PATIENTS AND METHODS

We performed a cross-sectional analysis of metabolic variables, in both the fasting state and after a liquid mixed-meal challenge, in four subject groups: 1) with clinically significant hypoglycemia [neuroglycopenia (NG)] after GB surgery, 2) with no symptoms of hypoglycemia at similar duration after GB surgery, 3) without GB similar to preoperative body mass index of the surgical cohorts, and 4) without GB similar to current body mass index of the surgical cohorts.

RESULTS

Insulin and C-peptide after the liquid mixed meal were both higher relative to the glucose level achieved in persons after GB with NG compared with asymptomatic individuals. Glucagon, glucagon-like peptide 1, and glucose-dependent insulinotropic peptide levels were higher in both post-GB surgical groups compared with both overweight and morbidly obese persons, and glucagon-like peptide 1 was markedly higher in the group with NG. Insulin resistance, assessed by homeostasis model assessment of insulin resistance, the composite insulin sensitivity index, or adiponectin, was similar in both post-GB groups. Dumping score was also higher in both GB groups but did not discriminate between asymptomatic and symptomatic patients. Notably, the frequency of asymptomatic hypoglycemia after a liquid mixed meal was high in post-GB patients.

CONCLUSION

A robust insulin secretory response was associated with postprandial hypoglycemia in patients after GB presenting with NG. Increased incretin levels may contribute to the increased insulin secretory response.

Benchmarking hospital outcomes for laparoscopic adjustable gastric banding

BACKGROUND

Since the Food and Drug Administration (FDA) approval of laparoscopic adjustable gastric bands (LAGB) in June 2001, the number LAGB procedures performed in the United States has increased exponentially. This study aimed to benchmark the authors' initial hospital experience to FDA research trials and evidence-based literature.

METHODS

Over a 2-year period, 87 consecutive patients with a mean age of 43 years (range, 21-64 years) and a body mass index of 45.6 kg/m2 (range, 35-69 kg/m2) underwent an LAGB procedure at the authors' institution. The authors conducted a retrospective review of the outcomes including conversion, reoperation, mortality, perforation, erosion, prolapse, port dysfunction, excess weight loss, and changes in comorbidities, then compared the data with published benchmarks.

RESULTS

Gender, age, and body mass index were comparable with those of other series. Perioperative adverse events included acute stoma obstruction (n = 1) and respiratory complications (n = 2). Delayed complications included gastric prolapse (n = 4) and port reservoir malposition (n = 4). Five bands were explanted. The mean follow-up period was 14 months (n = 79). The mean percentage of excess weight loss was 30% (range, 4.7-69%) at 6 months, 41% (range, 9.6-82%) at 12 months, and 47% (range, 14-92%) at 24 months. Comorbidities resolved included diabetes (74%), hypertension (57%), gastroesophageal reflux disease (55%) and dyslipidemia (38%).

CONCLUSIONS

The short-term outcomes for LAGB were comparable with published benchmarks. With adequate weight loss, most patients achieve significant improvement in obesity-related illnesses. With new bariatric accreditation standards and mandates required for financial reimbursement, hospitals will need to demonstrate that their clinical outcomes are consistent with best practices. The authors' early experience shows that LAGB achieves significant weight loss with low mortality and morbidity rates. Despite a more gradual weight loss, most patients achieve excellent weight loss with corresponding improvement of comorbidities within the first 2 years postoperatively.

Twenty-year audit of percutaneous liver biopsy in a major Australian teaching hospital

BACKGROUND

To examine the changes in indications, patient characteristics, safety and outcomes in consecutive patients undergoing percutaneous core liver biopsies in a major Australian teaching hospital over a period of two decades.

METHODS

A retrospective audit was carried out on all percutaneous core liver biopsies from a single institution between 1996 and 2005. This was combined with 10 years of data already reported on for the years 1986-1995 to detect trends in indications and outcomes.

RESULTS

Medical records from 1398 patients were included for analysis. Over a 20-year period, the most common indications for liver biopsy were hepatitis C (37.8%), hepatitis B (26.4%) and abnormal liver function tests (22.2%). Twelve major complications (1.0%) were seen; 10 episodes of haemorrhage, 1 bile leak and 1 visceral perforation. Seven of these patients had an abnormal baseline coagulation profile; a significant risk for major haemorrhage (P < 0.001), resulting in three deaths. All deaths occurred in inpatients with major comorbidities. Minor complications occurred in 13.6% of patients, with multiple passes a significant risk factor. Whereas the overall major and minor complication rates were independent of operator experience inadequate specimens were more frequently obtained by the registrar.

CONCLUSION

This large series extending over two decades shows that despite advances in biopsy techniques, the rates of both minor and major complications remain significant. Of particular concern are the procedure-related deaths. Identifying factors that may increase risk requires further scrutiny and careful patient selection needs to be undertaken.

Orbital based electronic structural signatures of the guanine keto G-7H/G-9H tautomer pair as studied using dual space analysis

Electronic structural signatures of the guanine-7H and guanine-9H tautomers have been investigated on an orbital by orbital basis using dual space analysis. A combination of density functional theory (B3LYP/TZVP), the statistical average of model orbital potentials (SAOP/TZ2P) method and outer valence Green's function theory (OVGF/TZVP) has been used to generate optimal tautomer geometries and accurate ionization energy spectra for the guanine tautomer pair. The present work found that the non-planar form for both of the guanine keto pair possesses lower energies than their corresponding planar counterparts, and that the canonical form of the guanine-7H tautomer has slightly lower total energy than guanine-9H. This latter result is in agreement with previous experimental and theoretical findings. In the planar guanine pair the geometric parameters and anisotropic molecular properties are compared, focusing on changes caused by the mobile proton transfer. It is demonstrated that the mobile proton only causes limited disturbance to isotropic properties, such as geometry and the energetics, of the guanine keto tautomer pair. The exception to this general statement is for related local changes such as the N((7))-C((8)) and C((8))-N((9)) bond length resonance between the single and double bonds, reflecting the nitrogen atom being bonded with the mobile proton in the tautomers. The mobile proton distorts the electron distribution of the tautomers, which leads to significant changes in the molecular anisotropic properties. The dipole moment of guanine-7H is altered by about a factor of three, from 2.23 to 7.05 D (guanine-9H), and the molecular electrostatic potentials also reflect significant electron charge distortion. The outer valence orbital momentum distributions, which were obtained using the plane wave impulse approximation (PWIA), have demonstrated quantitatively that the outer valence orbitals of the tautomer pair can be divided into three groups. That is orbitals 1a''-7a'' and 18a', which do not have visible alternations in the tautomeric process (which consist of either pi orbitals or are close to the inner valence shell); a second group comprising orbitals 19a'-22a', 25a', 26a', 28a', 29a' and 31a', which show small perturbations as a result of the mobile hydrogen locations; and group three, orbitals 23a', 24a', 27a', 30a' and 32a', which demonstrate significant changes due to the mobile proton transfer and are therefore considered as signature orbitals of the G-7H/G-9H keto tautomeric process.

Mechanically loaded ex vivo bone culture system 'Zetos': systems and culture preparation

This paper introduces the culture preparation of ovine, bovine and human cancellous bone cores to be used in an explants model Zetos. The three dimensional (3D) bone cores were prepared and evaluated for all three animals. Bone cells in vivo constantly interact with each other, migratory cells, surrounding extracellular matrix (ECM) and interstitial fluid in a microenvironment, which continuously responds to various endogenous and exogenous stimuli. The Zetos system was designed to culture and mechanically load viable cancellous bone explants in their near natural microenvironment. This 3D ex vivo system bridges the current gap between in vitro and in vivo methods. One aim of this work was to compare the macro and micro-architecture of ovine, bovine and human cancellous bone tissue in preparation for culture within the Zetos system in order to determine the optimal source of experimental material. A second aim was to optimise the preparations of the bone cores as well as develop techniques involved during tissue maintenance. Bone core response was visualised using histological and immunohistochemical methods. The results demonstrate that cancellous bone explants vary greatly in trabecular density and bone volume depending on species, age and location. Sheep and human samples displayed the greatest variation between bones cores when compared to bovine. Even cores taken from the same animal possessed very different characteristics. The histology demonstrated normal bone and cell structure after the core preparation. Immunohistochemistry results demonstrated antigen retention after preparation methods.

Prevalence and spectrum of bacterial co-infection during fungal keratitis

AIMS

To estimate the propensity of keratomycosis for parallel or secondary bacterial infection and to explore affinities among fungal and bacterial co-isolates.

METHODS

A retrospective review of laboratory records over 24 years yielded 152 episodes of culture positive fungal keratitis. After collating 65 corneal specimens having bacterial co-isolates, polymicrobial co-infection was defined as detection of concordant bacteria on smear and culture or on two or more different media.

RESULTS

30 (20%) keratomycoses met laboratory criteria for polymicrobial infection. The risk of bacterial co-infection was 3.2 (95% confidence interval, 1.7 to 5.8) times greater with yeast keratitis than with filamentous fungal keratitis.

CONCLUSIONS

Bacterial co-infection occasionally complicates fungal keratitis, particularly candidiasis.

The C-caffeine breath test distinguishes significant fibrosis in chronic hepatitis B and reflects response to lamivudine therapy

BACKGROUND

The 13C-caffeine breath test is a non-invasive, quantitative test of liver function.

AIM

To determine the utility of the 13C-caffeine breath test in chronic hepatitis B virus and its ability to monitor response to lamivudine.

METHODS

Forty-eight chronic hepatitis B virus patients and 24 controls underwent the 13C-caffeine breath test. In 28 patients commenced on lamivudine, 13C-caffeine breath tests were performed at 1 week (n = 12) and after 1 year of therapy.

RESULTS

Patients with Metavir F0-1 fibrosis (2.30 +/- 1.02 Delta per thousand per 100 mg caffeine) had a 13C-caffeine breath test similar to controls (2.31 +/- 0.85, P = 0.96). However, patients with F2-3 fibrosis (1.59 +/- 0.78, P = 0.047) and cirrhotic patients (0.99 +/- 0.33, P = 0.001) had a decreased 13C-caffeine breath test. Fibrosis correlated best with the 13C-caffeine breath test (r(s) = -0.62, P < 0.001). The 13C-caffeine breath test independently predicted significant (F > or = 2) and advanced (F > or = 3) fibrosis and yielded the greatest area under the receiver operating characteristic curve (0.91 +/- 0.04) for predicting advanced fibrosis. The 13C-caffeine breath test was unaltered by 1 week of lamivudine but improved by 61% (P < 0.001) in responders to long-term lamivudine, whereas in those with viraemia and elevated alanine aminotransferase, values remained stable or deteriorated.

CONCLUSION

The 13C-caffeine breath test distinguishes chronic hepatitis B virus-related fibrosis and detects improvement in liver function in response to long-term lamivudine.

Mechanosensitivity of human osteosarcoma cells and phospholipase C β2 expression

Bone adapts to mechanical load by osteosynthesis, suggesting that osteoblasts might respond to mechanical stimuli. We therefore investigated cell proliferation and phospholipase C (PLC) expression in osteoblasts. One Hertz uniaxial stretching at 4000 microstrains significantly increased the proliferation rates of human osteoblast-like osteosarcoma cell line MG-63 and primary human osteoblasts. However, U-2/OS, SaOS-2, OST, and MNNG/HOS cells showed no significant changes in proliferation rate. We investigated the expression pattern of different isoforms of PLC in these cell lines. We were able to detect PLC beta1, beta3, gamma1, gamma2, and delta1 in all cells, but PLC beta2 was only detectable in the mechanosensitive cells. We therefore investigated the possible role of PLC beta2 in mechanotransduction. Inducible antisense expression for 24h inhibited the translation of PLC beta1 in U-2/OS cells by 35% and PLC beta2 in MG-63 by 29%. Fluid shear flow experiments with MG-63 lacking PLC beta2 revealed a significantly higher level of cells losing attachment to coverslips and a significantly lower number of cells increasing intracellular free calcium.

Basic reactions of osteoblasts on structured material surfaces

In order to assess how bone substitute materials determine bone formation in vivo it is useful to understand the mechanisms of the material surface/tissue interaction on a cellular level. Artificial materials are used in two applications, as biomaterials alone or as a scaffold for osteoblasts in a tissue engineering approach. Recently, many efforts have been undertaken to improve bone regeneration by the use of structured material surfaces. In vitro studies of bone cell responses to artificial materials are the basic tool to determine these interactions. Surface properties of materials surfaces as well as biophysical constraints at the biomaterial surface are of major importance since these features will direct the cell responses. Studies on osteoblastlike cell reactivity towards materials will have to focus on the different steps of protein and cell reactions towards defined surface properties. The introduction of new techniques allows nowadays the fabrication of materials with ordered surface structures. This paper gives a review of present knowledge on the various stages of osteoblast reactions on material surfaces, focused on basic cell events under in vitro conditions. Special emphasis is given to cellular reactions towards ordered nano-sized topographies.

Simulated laparoscopy using a head-mounted display vs traditional video monitor: an assessment of performance and muscle fatigue

BACKGROUND

The direction of visual gaze may be an important ergonomic factor that affects operative performance. We designed a study to determine whether a head-mounted display (HMD) worn by the surgeon would improve task performance and/or reduce muscle fatigue during a laparoscopic task when compared to the use of a traditional video monitor display (VMD).

METHODS

Surgical residents (n = 30) were enrolled in the study. A junior group, consisting of 15 postgraduate year (PGY) = 1 subjects with no previous laparoscopic experience, and a senior group, consisting of 15 PGY 4 and PGY 5 subjects with experience, completed a laparoscopic task that was repeated four times using the Computer Enhanced Laparoscopic Training System (CELTS). Groups alternated between using the HMD with the task placed in a downward frontal position and the VMD with the task at a 30 degrees lateral angle. The CELTS module assessed task completion time, depth perception, path length of instruments, response orientation, motion smoothness; the system then generated an overall score. Electromyography (EMG) was used to record sternocleidomastoid muscle activity. Display preference was surveyed.

RESULTS

The senior residents performed better than the junior residents overall on all parameters (p < 0.05) except for motion smoothness, where there was no difference. In both groups, the HMD significantly improved motion smoothness when compared to the VMD (p < 0.05). All other parameters were equal. There was less muscle fatigue when using the VMD (p < 0.05). We found that 66% of the junior residents but only 20% of the senior residents preferred the HMD.

CONCLUSIONS

The CELTS module demonstrated evidence of construct validity by differentiating the performances of junior and senior residents. By aligning the surgeon's visual gaze with the instruments, HMD improved smoothness of motion. Experienced residents preferred the traditional monitor display. Although the VMD produced less muscle fatigue, inexperienced residents preferred the HMD, possibly because of improved smoothness of motion.

Optimal management of the morbidly obese patient SAGES appropriateness conference statement

BACKGROUND

Obesity is a growing health problem that contributes to numerous life-threatening or disabling disorders, including coronary artery disease, hypertension, type 2 diabetes mellitus, hyperlipidemia, degenerative joint disease, and obstructive sleep apnea. Significant weight reduction in the morbidly obese improves or reverses associated illness and benefits well-being. The purpose of the SAGES Appropriateness Conference was to summarize the state of the art for open and laparoscopic operations for the morbidly obese.

METHODS

The English literature comparing bariatric procedures was reviewed and grouped by level of evidence by three surgeons (BS, LV, and CC). From more than 1,500 articles, all conference participants were provided with reprints and table summaries of no less than 50 selected manuscripts. Ten experts were requested to present reviews and make evidence-based arguments for and against the open and laparoscopic approaches in written format. An expert panel of six surgeons, including an ethicist and patient, commented on implications of data presented. The finalized statement was e-mailed to all participants for approval and comment.

RESULTS

Consensus statements were achieved on various aspects of morbid obesity, including indications for surgery, resolution of comorbid illnesses with significant weight loss, and the importance of committed bariatric program. Our panel of experts agreed, in general, to the advantages of laparoscopic approaches compared to open operations in skilled hands.

CONCLUSIONS

Laparoscopic Roux-en-Y gastric bypass (RYGB) affords improved short-term recovery compared to open gastric bypass. Laparoscopic adjustable banding can be performed with lower average mortality than either RYGB or any of the malabsorptive operations, and it produces variable degrees of short-term weight loss. Prospective randomized trials are needed to compare gastric bypass, malabsorptive, and restrictive procedures.