Initial clinical experience with telemetrically adjustable gastric banding

BACKGROUND

The feasibility and safety of laparoscopic adjustable gastric banding for treatment of morbid obesity has been demonstrated in a large number of studies. Access port-related complications constitute a significant part of all complications related to gastric banding. Further, adjustment of hydraulic gastric bands can be fairly lengthy, uncomfortable, and is not a precise procedure. A study was performed to assess the usefulness and efficacy of a new type of band adjusted telemetrically without the need for an access port. The initial worldwide results of the first telemetrically adjustable gastric band for morbid obesity (EASYBAND EndoArt Medical Technologies, Switzerland) in two German academic centers are described herein.

METHODS

EASYBAND is a purely mechanical gastric band, in which adjustment is achieved by means of an embedded micromotor, controlled by an external control unit using telemetry. The exact band diameter is displayed continuously during adjustment on the external control unit screen. Thirty-seven patients, means 36 +/- 8 (range: 22-60) years, 7 (19%) men and 30 (81%) women, with a mean body mass index (BMI) of 44.1 +/- 4.5 (range: 35.6-59.6), were implanted using the standard laparoscopic technique during the period from June 2005 to October 2005. Prospective data were collected on all morbidly obese patients who underwent laparoscopic telemetrically adjustable gastric banding (LTAGB).

RESULTS

No serious adverse events occurred during the operative period or immediately postoperatively in relation to the device. A mean of 3.0 +/- 0.6 adjustments per patients were performed during the follow-up schedule at one, three and six months. The band diameter was set to 29 mm (fully open) at implantation, 24.5 mm +/- 0.5 mm at one month, 23.3 mm +/- 0.7 mm at three months, and 23.0 mm +/- 1.0 mm at six months. The mean percent excess weight loss was 10.2% +/- 4.5% at one month, 23.8% +/- 8.8% at three months, and 30.2% +/- 10.5% at six months.

CONCLUSION

This initial study shows that the new telemetrically adjustable gastric banding device is implanted and operated safely, allows for atruamatic band adjustments with superior patient comfort, and leads to early excess weight loss comparable to that achieved by other gastric bands. Longer-term follows and larger population studies are needed to establish the final safety and performance profile of the telemetric gastric band.

Current issues and challenges in the management of bariatric patients

Morbid obesity is an increasingly common healthcare problem, and providers and patients currently face numerous challenges in dealing with this problem effectively. Issues addressed in this article include the effect of stigma, the need for more evidence regarding effective management options, and the declining insurance coverage for bariatric surgery. The role of bariatric surgery in effective management of morbid obesity is discussed, along with the effect on and possible reasons for declining coverage. A comparison between benefits and coverage for bariatric surgery and angioplasty/stent placement is included.

Nonsurgical and surgical treatment of obesity

An increasing number of morbidly obese patients are presenting for surgery, with the potential for increased perioperative morbidity and mortality. This article reviews surgical and nonsurgical options in the management of morbidly obese patients. Overweight and obese individuals should be treated with diet, exercise, and behavioral therapy. The failure of this approach is an indication for pharmacologic therapy. Bariatric surgery reduces obesity-related complications and reduces long-term morbidity, mortality, and health care resources use.

Laparoscopic sleeve gastrectomy as an initial bariatric operation for high-risk patients: initial results in 10 patients

BACKGROUND

The outcomes and initial results of laparoscopic sleeve gastrectomy were evaluated.

METHODS

A prospective study of the initial 10 patients who underwent laparoscopic sleeve gastrectomy (LSG) was performed. Study endpoints included operative time, complication rates, hospital length of stay and percentage of excess weight loss (%EWL).

RESULTS

There were 5 women and 5 men, with mean age 43 years (range 31 to 52). Mean preoperative weight was 182 kg (range 125-247 kg), with mean preoperative BMI 64 (range 61-80). Indication for LSG was related to BMI in all patients. 1 patient had previous restrictive bariatric surgery. Mean operative time was 2 hours (range 1.5-2.5). No patient required conversion. There were no postoperative complications nor mortality. Median hospital stay was 7.2 days. Average %EWL and BMI at 1 year were 51% and 23 kg/m2, respectively.

CONCLUSION

LSG can be safely integrated into a bariatric surgical program with good results in terms of weight loss and quality of life. LSG can be a firststage procedure before gastric bypass or duodenal switch or a one-stage restrictive procedure if longterm results are good. LSG should be considered as a surgical option in the bariatric field.

Staged laparoscopic Roux-en-Y: a novel two-stage bariatric operation as an alternative in the super-obese with massively enlarged liver

In a subset of super-obese patients, the one-stage laparoscopic Roux-en-Y gastric bypass (RYGBP) can be associated with significant morbidity and mortality. In a previous effort to reduce the perioperative risks associated with the super-obese, a two-stage operation was devised. This two-stage operation consisted of a sleeve gastrectomy (1st stage) followed by a RYGBP or duodenal switch procedure (2nd stage). We find that the primary limiting factor making laparoscopic gastric bypass challenging in the super-obese is the volume of the left lobe of the liver. A greatly thickened left lobe of the liver obscures visualization of the gastroesophageal junction and angle of His so that a sleeve gastrectomy is difficult to construct. In this report, we describe a novel method utilizing a staged Roux-en-Y procedure. Instead of performing a restrictive operation (sleeve gastrectomy) as the initial procedure, we fashion a modified Roux-en-Y with a low gastrojejunal anastomosis and a larger gastric pouch encompassing the gastric fundus. The low anastomosis obviates the need for exposure of the gastro-esophageal junction and angle of His. At the 2nd stage procedure, completion sleeve gastrectomy of the gastric fundus is performed at an interval of 6-12 months after the 1st stage operation.

Obesity: basic science and medical aspects relevant to anaesthetists

Obesity is becoming a major public health problem throughout the world. It is now the second leading cause of death in the United States and is associated with significant, potentially life-threatening co-morbidities. Significant advances in the understanding of the physiology of body weight regulation and the pathogenesis of obesity have been achieved. A better understanding of the physiology of appetite control has enabled advances in the medical and surgical treatment of obesity. Visceral or abdominal obesity is associated with an increased risk of cardiovascular disease and type 2 diabetes. Various drugs are used in the treatment of mild obesity but they are associated with adverse effects. Surgery has become an essential part of the treatment of morbid obesity, notwithstanding the potential adverse events that accompany it. An appreciation of these problems is essential to the anaesthetist and intensivist involved in the management of this group of patients.

Obesity, weight loss and bariatric surgery

Obesity is shaping up to be the major health care problem and one of the most frequent causes of preventable death in Western countries in the 21st century. Bariatric surgery is the only current treatment that has been shown to achieve major and durable weight loss. Major weight loss in the severely obese leads to total or partial control of a wide range of common and serious diseases, such as diabetes, heart disease and hypertension. Laparoscopic adjustable gastric banding is the most common type of obesity surgery performed in Australia. It is effective, relatively safe and minimally invasive. The blocks to broader application of bariatric surgery should be identified and resolved.

Patients Postoperatively Forget Aspects of Preoperative Patient Education

BACKGROUND

Preoperative patient education is critically important to the success of any bariatric operation. In our clinic, we perform extensive preoperative education and informed consent. Part of the informed consent process includes a preoperative true/false quiz. This study tests the hypothesis that postoperative patients do not recall key components of their preoperative education.

METHODS

Preoperatively, all patients were required to take the true/false quiz and retake it, if necessary, until they received all the questions correct. All patients were given their preoperative informed consent quiz again at least 1 month after laparoscopic gastric bypass, during their postoperative clinic visit. Patients >1 year postoperatively from surgery were compared to patients <1 year postoperatively.

RESULTS

63 patients were included in this study. Originally, 46% of patients did not get all the questions correct the first time; mean score on the quiz preoperatively was 95%. Patients took the test an average of 8 months after surgery. Postoperatively, 46% of patients did not get all the questions correct; mean score on the quiz was 96%. The 2 most common incorrect answers were: "Obesity surgery is basically an aid to dieting: it does not mean that you will lose weight no matter what you eat or do (True)" and "Diabetes, high blood pressure, back pain and similar ailments always get better after obesity surgery (False)". Patients >1 year postoperative were more likely not to get all the questions correct (80% vs 36%; P<0.01; two-tailed Fisher's exact test).

CONCLUSIONS

Patients do not remember basic preoperative education facts after their bariatric surgery. Despite maximal efforts in verifying preoperative education, patients often forget this critical information after bariatric surgery. Patients 1 year after surgery forget more information.

Current Indications for Preoperative Inferior Vena Cava Filter Insertion in Patients Undergoing Surgery for Morbid Obesity

BACKGROUND

Pulmonary embolus is a potentially lethal complication in patients undergoing surgery for morbid obesity. In a select group of patients at high risk for venous thromboembolic events (VTE), we have chosen to prophylactically insert inferior vena cava filters via a jugular percutaneous approach. We propose guidelines for preoperative insertion of inferior vena cava filters in patients with clinically significant obesity.

METHODS

All patients who underwent preoperative insertion of inferior vena cava (IVC) filters as prophylaxis for pulmonary emboli were reviewed. Data regarding body mass index (BMI), prior history of venous thromboembolism, current anticoagulant usage, as well as other patient data were compiled and analyzed. Additionally, all operative notes were reviewed, and operative data were analyzed and compared.

RESULTS

14 patients underwent preoperative IVC filter placement before gastric bypass. Mean patient age was 49.1 +/- 1.52 years and mean BMI was 56.5 +/- 4.45 kg/m2. No complications occurred due to preoperative filter placement, and no pulmonary emboli occurred in this group. Indications for preoperative IVC filter insertion included prior pulmonary embolus (6), prior deep venous thrombosis (7), and lower extremity venous stasis (1).

CONCLUSIONS

Vena caval filter placement in the preoperative period can be undertaken safely in bariatric patients. We recommend that routine preoperative vena caval filter placement should be undertaken in all bariatric patients with prior pulmonary embolus, prior deep venous thrombosis, evidence of venous stasis, or known hypercoagulable state. Possible roles for IVC filter placement in this patient population are expanding as more data is acquired.

Minimal Reporting Requirements for Weight Loss: Current Methods Not Ideal

BACKGROUND

There is variety in the reporting of weight loss outcomes within the bariatric literature. Our aim is to compare methods of reporting weight loss in surgical and medical studies, and in addition look for a minimal reporting requirement that allows meaningful comparison.

METHOD

A review of methods of reporting weight loss in studies published during 2004 was conducted. Bariatric surgical studies included all reports from MEDLINE-listed journals, and medical studies included reports of non-surgical weight loss from 9 leading journals.

RESULTS

65 surgical and 36 non-surgical reports were retrieved. There were 3 common (>20% of reports) methods of reporting in the surgical literature; mean weight, percentage of excess weight loss (%EWL) and body mass index (BMI), and 4 in the medical literature; mean weight loss, weight, percentage weight loss and BMI. %EWL was reported in 2/3 of surgical reports and in none of the non-surgical. The origin of ideal weight for %EWL calculations was reported in 10 (23%) of these studies and included 5 differing definitions. All methods of reporting other than those using "ideal weight" can be calculated from mean weight and BMI at all time-points.

CONCLUSION

There is complexity and confusion in the reporting of bariatric surgery weight outcomes when calculations are based on ideal weight. Providing weight (kg) and BMI (kg/m2) at all time-points allows the reader to interpret and compare the results in the context of the population of interest. These two measures should be provided as a minimum by all journals reporting on intentional weight loss.

An evaluation of bariatric Web sites for patient education and guidance

Bariatric surgery for the treatment of obesity has become a trend, with television and music celebrities touting it as a cure. There has been an extraordinary growth rate in the number of people each year undergoing bariatric surgery, and many of these patients are obtaining their information about the surgery from the Internet. As more and more people turn to the Internet for healthcare information, the need to monitor those Web sites for accuracy and quality expands. The purpose of this study was to assess bariatric Web sites for their quality and accuracy of information. Forty Web sites were evaluated using the Health Information Technology Institute (HITI) criteria and five evaluation criteria based on guidelines from the National Institutes of Health (NIH); the readability of the sites also was determined. Web sites were identified for the purpose of patient education and guidance about this explosive topic.

The Bariatric Quality of Life index: a measure of well-being in obesity surgery patients

BACKGROUND

Quality of life (QoL) is considered to be the true measure for the effectiveness of a surgical procedure, but there are only a few validated instruments available for bariatric surgery. Therefore, a new diseasespecific 30-item instrument was created, which was called Bariatric Quality of Life (BQL) questionnaire.

METHODS

To validate the BQL, we studied 133 patients after 4 different types of bariatric surgery. Initially, mean body mass index (BMI) was 47.2 +/-7.6 kg/m2 and mean age was 38.8 +/-11.0 years. At baseline, and 1, 6, and 12 months after surgery, patients filled in the BQL, the SF-12 (Short Form of SF-36 Health Survey), the GIQLI (Gastrointestinal Quality of Life Index), and the BAROS (Bariatric Analysis and Reporting Outcome System).

RESULTS

Internal consistency of the BQL was found to be good, with Cronbach's alpha ranging between 0.71 and 0.86. Factor analyses suggested that the BQL included a highly consistent set of QoL items and a second part on co-morbidities and gastrointestinal symptoms. At the 12 months follow-up, the BQL was closely correlated to SF 12 (Pearson's r = 0.86), GIQLI (0.68), BAROS (0.71), and excess weight loss (0.55). Standardized effect sizes over time were larger for the BQL (1.39 and 1.58) than for the other instruments.

CONCLUSIONS

The BQL questionnaire is a validated instrument ready for clinical use.

Bariatric surgery: assessing opportunities for value innovation

Obesity has been increasing over the past two decades, and the amount of medical and media attention given to bariatric surgery as a promising option for morbidly obese individuals is growing. The growth of bariatric surgery also has been attributed to improved surgical technique, the increase in surgeons trained in laparoscopic procedures, as well increased public awareness with celebrities having successfully undergone surgery. The number of surgeons and hospitals offering bariatric services is increasing. How then does a surgeon or a hospital develop a competitive strategy? The first step is to understand the health-care industry. The key forces are rivalry among present competitors, and the bargaining power of suppliers and buyers. While bariatric surgery currently is in a growth phase, time and competition will force practitioners to compete on the basis of price, unless they find true competitive advantage. Value innovation, is a means of creating new marketing space by looking across the conventionally defined boundaries of business--across substitute industries, across strategic groups, across buyer groups, across complementary product and service offerings, and across the functional-emotional orientation of an industry. One can compete by offering similar services focusing primarily on cost efficiencies as the key to profitability. Alternatively, one can break free from the pack by innovating and focusing on delivering superior value to the customer. As the market for bariatric surgery becomes increasingly overcrowded, profitable growth is not sustainable without developing a clear differential advantage in the market. Value innovation allows you to develop that advantage.

The management of obesity: the role of the specialist nurse

Obesity is a global problem, independent of age. The numbers of obese individuals are now reaching epidemic proportions around the world. This is contributing to the risk of inherent comorbidity. The pathophysiology of obesity, although widely debated, is still unclear with suggestions that multiple genetic mutations may have a key role in the development, but as yet no one genetic mutation is felt to be entirely responsible. Biochemical manifestations such as diabetes may play a role. The first goal of management of the obese patient will involve dietary and behavioural modification and a programme of physical exercise. In primary care settings, nurses are suitably placed to assess and manage obese patients (National Institute for Clinical Excellence (NICE), 2001a). The nursing profession needs to rise to the challenge and prepare nurses for a specialist role in obesity management.

National study of the effect of patient and hospital characteristics on bariatric surgery outcomes

The influence of patient and hospital demographics on gastric bypass (GB) outcomes is unknown. We analyzed year 2000 data from the Nationwide Inpatient Sample database for all GB patients. In 2000, 5876 GB were performed in the 137 sample hospitals (M:F, 14%:86%). Length of stay (LOS, days), charges, comorbidities, and morbidity were higher for those aged >60 years compared to < 40 years. LOS, charges, comorbidities, morbidity, and mortality were highest in males. LOS was longest in African Americans compared to Caucasians and Hispanics. Charges and comorbidities were greatest in African Americans and Hispanics compared to Caucasians. Medicare and Medicaid-insured patients have higher LOS, charges, comorbidities, morbidity, and mortality compared to privately insured and self-pay patients. Lower income patients have higher LOS and total charges. Nonteaching hospitals have an increased LOS and charges and treat patients with more comorbidities compared to teaching hospitals. LOS, charges, and morbidity are directly proportional to hospital size. Urban hospitals have lower LOS and higher charges compared to rural hospitals. As hospital GB volume increases, LOS, charges, and morbidity decrease with no mortality effect. After controlling for all other covariates, male gender, increased age, and large hospital size were predictors of increased morbidity. Having had a complication predicted increased mortality, while female gender had a protective effect. Patient income, insurance status, and race did not play a role in morbidity or mortality. Neither academic, teaching status of the hospital or hospital gastric bypass volume influenced patient outcomes. Patient and hospital demographics do affect the outcomes of patients undergoing GB. Increasing age, male gender, and surgery performed in large hospitals are predictors of morbidity. Male gender and postoperative complications predict increased mortality. Neither comorbidities, race, payer, income, hospital academic status, location, nor hospital volume affect the outcome after GB.