Results and complications after adjustable gastric banding in a series of 250 patients

Laparoscopic Adjustable Gastric Band Slippage Rates Following Laparoscopic Gastric Band Insertion: a Single Centre Experience

INTRODUCTION

Laparoscopic adjustable gastric bands (LAGB) are placed around the superior aspect of the stomach to aid weight loss and co-morbidity resolution in morbidly obese patients. Slippage of the LAGB from its original position to lower in the fundus of the stomach leads to gastric obstruction, and sometimes ischaemia or perforation, necessitating LAGB repositioning or removal. This study aimed to identify the incidence of LAGB slippage, as well as predisposing factors that may influence its development.

METHODS

All LAGBs inserted at one centre, via a pars flaccida technique, by four Bariatric specialist consultants, were reviewed utilising a prospectively maintained Bariatric database, computer records and case notes review.

RESULTS

Seven hundred nineteen LAGBs were inserted and 33 slips treated; however, only 22 slips had their LAGB inserted at our centre (local slip rate 3.1 %). Multivariate analysis demonstrated a significant association between LAGB slip and younger median age at LAGB insertion (41 years slip vs. 45 years non-slip; p = 0.027), higher median total excess weight loss (64 % slip vs. 36 % non-slip; p < 0.001) and higher mean excess weight loss per month (2.41 % slip vs. 1.00 % non-slip; p < 0.001). There was no significant effect by sex, BMI at insertion or band type.

CONCLUSIONS

Band slips are associated with greater excess weight loss and younger age. Larger studies may be necessary to further elucidate the risk factors contributing to, and mechanisms of, band slippage.

Asymptomatic Gastric Band Erosion Detected during Routine Gastroduodenoscopy

The incidence of gastric band erosion has decreased to 1%. Gastric band erosion can manifest with various clinical symptoms, although some patients remain asymptomatic. We present a case of a mostly asymptomatic patient who was diagnosed with gastric band erosion during a routine health check-up. A 32-year-old man without any underlying diseases except for non-alcoholic fatty liver underwent laparoscopic adjustable gastric band surgery in 2010. He had no significant complications postoperatively. He underwent routine health check-ups with near-normal gastroduodenoscopic findings through 2014. However, in 2015, routine gastroduodenoscopy showed that the gastric band had eroded into the stomach. His gastric band was removed laparoscopically, and the remaining gastric ulcer perforation was repaired using an omental patch. Due to the early diagnosis, the infection was not serious. The patient was discharged on postoperative day 3 with oral antibiotics. This patient was fortunately diagnosed early by virtue of a routine health check-up; thus, eliminating the possibility of serious complications.

Percutaneous Revision of a Testicular Prosthesis is Safe, Cost-effective, and Provides Good Patient Satisfaction

Office-based percutaneous revision of a testicular prosthesis has never been reported. A patient received a testicular prosthesis but was dissatisfied with the firmness of the implant. In an office setting, the prosthesis was inflated with additional fluid via a percutaneous approach. Evaluated outcomes included patient satisfaction, prosthesis size, recovery time, and cost savings. The patient was satisfied, with no infection, leak, or complication after more than 1 year of follow-up, at significantly less cost than revision surgery. Percutaneous adjustment of testicular prosthesis fill-volume can be safe, inexpensive, and result in good patient satisfaction.

Recurrent aspiration pneumonia after laparoscopic adjustable gastric banding for obesity surgery

Laparoscopic adjustable gastric banding (LAGB) is an increasingly common therapeutic option in the management of obesity and certain obesity-related comorbid conditions. As it gains popularity for its advantages of being minimally invasive and reversible, clinicians should be aware of growing evidence of esophageal and pulmonary complications, which may be irreversible and associated with long-term morbidity. We report a case of esophageal and pulmonary complications in a patient with successful weight loss after lap-band surgery necessitating its removal.

Significant weight loss and rapid resolution of diabetes and dyslipidemia during short-term follow-up after laparoscopic sleeve gastrectomy

BACKGROUND

Bariatric surgery has been established as the best option of treatment for morbid obesity. Recently, laparoscopic sleeve gastrectomy (SG) has become very popular because of good postoperative weight loss and low morbidity. The aim of this study was to report our single-center experience with SG regarding feasibility, morbidity, and outcome.

METHODS

From January 2006 to December 2011, 93 patients (68 female) with a median age of 46 years underwent laparoscopic SG at our department. Thirteen patients had a history of gastric banding with insufficient weight loss or band-related complications. Clinical outcome and laboratory findings were analyzed.

RESULTS

The mean preoperative and postoperative body mass index (BMI) was 44.1 ± 6.9 and 33.4 ± 6.8 kg/m(2), respectively (p < 0.001). The mean excessive body weight loss after a median follow-up of 11.9 months was 55.7 % ± 24.9 %. Three bleedings, two staple line leakages, and a deep wound infection required conversion to laparotomy (n = 1), reoperation (n = 4), or endoscopic stent implantation (n = 2). Resolution of diabetes and dyslipidemia was seen in 85 and 50 % of patients, respectively. Blood test results of HbA1c, cholesterols, triglycerides, and leptin showed significant postoperative improvement.

CONCLUSIONS

Laparoscopic SG represents a feasible bariatric procedure with good short-term weight loss, low morbidity rate, and efficient resolution of diabetes and dyslipidemia, especially in patients with lower BMI. The significant decrease of leptin necessitates further studies to understand the ambiguous role of leptin in bariatric surgery.

Long-term effects of weight loss after bariatric surgery on functional and structural markers of atherosclerosis

OBJECTIVE

Pronounced weight loss after bariatric surgery was demonstrated to have significant beneficial effects on surrogates of early atherosclerosis. The aim of this prospective examination was to investigate whether these improvements of endothelial function and vascular structure are persistent in the long-term.

DESIGN AND METHODS

A total of 52 obese adults were examined before and 5 years after bariatric surgery. Carotid intima media thickness (IMT), brachial flow-mediated dilation (FMD), abdominal fat distribution, and metabolic parameters were determined. Additional 18 months data were available from 27 patients.

RESULTS

After 5 years, mean weight loss ± SD of 25% ± 12 in all subjects was accompanied by known improvements in metabolism. Change in IMT was -0.02 mm ± 0.007, whereas FMD improved by +1.5% ± 0.5. In the subgroup IMT decreased by 0.04 mm ± 0.06 within the first 18 months, whereas no significant change was observed between 18 month and 5 years. FMD improved by 3.8% ± 0.6 after 18 months followed by a nonsignificant decrease of -1.4% ± 0.9.

CONCLUSIONS

These long-term results demonstrate that bariatric surgery-induced weight loss improves both functional and structural markers of early atherosclerosis providing further evidence for the beneficial effects of weight loss on obesity-associated alterations of the vasculature.

Plasminogen activator inhibitor 1 and visceral obesity during pronounced weight loss after bariatric surgery

BACKGROUND AND AIMS

Elevated plasminogen activator inhibitor 1 (PAI-1) concentrations are a hallmark of obesity and are considered to contribute to the development of cardiovascular disease. As adipose tissue constitutes a major source for PAI-1 in obesity, we investigated the individual contribution of subcutaneous and intra-abdominal fat on PAI-1 concentrations during pronounced weight loss after bariatric surgery.

METHODS AND RESULTS

Thirty-seven obese adults were examined before and 18 months after surgery. Abdominal fat distribution was determined by ultrasound, metabolic parameters and plasma PAI-1 levels by standard methods. BMI was reduced by 9.2 ± 4.9 kg/m(2), while total fat mass and visceral fat diameter (VFD) decreased by 20.7 ± 11.9 kg and 4.2 ± 2.3 cm, respectively. Concomitantly, PAI-1 levels diminished by 3.2 ± 5.6 ng/ml (all p ≤ 0.015). Change in PAI-1 levels was correlated with change in VFD (r = 0.441, p = 0.008), but not with subcutaneous fat diameter. In stepwise multiple regression analysis change in VFD was an independent predictor of change in PAI-1 concentrations. When adjusted for age and sex or total fat mass associations between PAI-1 and VFD remained significant.

CONCLUSION

We demonstrate that VFD is a major determinant for PAI-1 concentrations during pronounced weight loss after bariatric surgery. Thus, significant reduction of visceral fat mass may contribute to the reduced cardiovascular morbidity and mortality after bariatric surgery by a concomitant decrease in PAI-1 concentrations.

Long-term outcome after laparoscopic adjustable gastric banding for morbid obesity

This study was performed to determine the long-term consequences of laparoscopic gastric banding on weight loss, body image, and life quality in morbidly obese patients. After a minimum follow-up of 9 years (mean follow-up 10 years; range 9-12 years) several questionnaires concerning weight loss, body image, and life quality were mailed to 180 morbidly obese patients following laparoscopic adjustable gastric banding. One hundred and twelve (62%) patients (92 females, 20 males) completed and returned the questionnaires. Of the entire sample, 73 (64.9%) patients still had the first band, 17 (15.3%) a second band, and in 22 (19.8%) probands the band had been removed for various reasons. Average weight loss, calculated as change in body mass index, was 13.9 kg/m². Average excess weight loss (EWL) was 30.6%. A total of 10% patients accounted for >50% of EWL. Half of the probands were completely satisfied with their weight loss and about half had reached their planned weight. Lowest post-operative weight was reached at different times, in nearly half of the probands after 2 years, in one-fourth after 4-5 years, and in about 20% at a later time. More than 90% of the probands experienced longer interruptions in weight loss; about half knew why. The findings indicate that overall quality of life was rated good to excellent by two-thirds of the probands, and fair to poor by one-third. A close correlation was seen between extent of weight loss and quality of life and body image. Despite some limitations, laparoscopic adjustable gastric banding is an effective and safe long-term surgical treatment for a majority of morbidly obese individuals, resulting in long-term weight loss and health-related quality of life. However, there is also a minority of morbidly obese subjects who do not benefit enough from this kind of bariatric surgery. Future research should investigate what kind of bariatric surgery is best for the particular obese individual in order to minimize unsatisfying post-operative results.

Effect of weight loss on serum pigment epithelium-derived factor levels

BACKGROUND

Cumulating evidence suggests that the broadly acting neurotrophic pigment epithelium-derived factor is associated with visceral adiposity, the metabolic syndrome, diabetes and exerts beneficial effects on atherosclerosis. To further elucidate the relationship between pigment epithelium-derived factor and metabolic perturbations characteristic of obesity, we examined the effect of pronounced weight loss on serum levels of pigment epithelium-derived factor.

MATERIALS AND METHODS

Thirty-six severely obese adults were examined before and 18 months after bariatric surgery. Abdominal fat distribution was determined by ultrasound, metabolic parameters by standard methods, pro-inflammatory biomarkers and serum pigment epithelium-derived factor levels by enzyme-linked immunosorbent assay.

RESULTS

Bariatric surgery resulted in a mean body mass index (BMI) reduction of 9·0 ± 5·0 kg m(-2) and concomitant improvements in glucose homoeostasis and lipid profile. Pigment epithelium-derived factor serum levels decreased from a median 11·0 μg mL(-1) (interquartile range: 3·8) to 9·2 μg mL(-1) (interquartile range: 4·5) (P < 0·0001). In univariate analysis, relative change in pigment epithelium-derived factor levels was significantly associated with change in weight, BMI, fat mass, visceral fat diameter, insulin, homoeostasis model for insulin resistance, triglyceride and leptin levels (all r > 0·370, P < 0·05). No associations were observed for C-reactive protein, interleukin-6 or tumour necrosis factor alpha. After adjustment for age, sex and smoking status, associations remained significant.

CONCLUSIONS

The beneficial effects of bariatric surgery-induced pronounced weight loss on glucose homoeostasis may partially be attributable to visceral adipose tissue reduction and concomitantly decreasing pigment epithelium-derived factor concentrations.

Long-term results and complications following adjustable gastric banding

This study was performed to assess our long-term results with laparoscopic gastric banding in patients with an observation period of at least 9 years calculated from the date of operation. Between January 1996 and December 2000, a total of 276 patients (83% female) underwent laparoscopic gastric banding at our institution. Mean preoperative body mass index (BMI) was 44 +/- 6 kg/m(2). BMI after 1, 5, 7, 9, and 10 years was 33 +/- 6, 30 +/- 6, 31 +/- 6, 32 +/- 7, and 31 +/- 7 kg/m(2), respectively. Mean excess weight loss after 1 year was 57.1 +/- 23.0% and after 5, 7, 9, and 10 years 73.2 +/- 29.6%, 65.9 +/- 29.3%, 61.8 +/- 32.8%, and 64.0 +/- 32.1%, respectively. Median completeness of follow-up was 80%. Of the study population, 146 (52.9%) patients had at least one complication requiring reoperation. Presently, only 148 (53.6%) patients still have their original band, 49 (17.8%) had their original band replaced with a new one, and 79 (28.6%) had their band removed. Thirty-three patients had no second bariatric operation, a Roux-en-Y gastric bypass was done in 39 patients, and six patients underwent sleeve gastrectomy. Our long-term results are good with regard to weight loss in those patients who still have their band in situ. This is accompanied by a high complication rate and a 29% band loss rate.

Severe peritonitis due to Streptococcus viridans following adjustable gastric banding

Late postoperative intra-abdominal infections after laparoscopic gastric banding are extremely rare and may or may not be associated with the device following uncomplicated adjustable gastric banding procedures. The spectrum of pathogens associated with intra-abdominal infections is diverse and depends on the origin of the infection. Streptococci is a significant cause of peritoneal dialysis peritonitis (6% to 16% of the cases), and S. viridans is reported to account for up to 93% of streptococci infections. However, peritonitis due to S. viridans in patients following adjustable gastric banding is very rare. We herein report a non-uremic case of a 38-year-old male patient with severe peritonitis due to S. viridans 5 years after an uneventful primary gastric banding procedure.

Weight loss and quality of life after gastric band removal or deflation

BACKGROUND

The study aim was to retrospectively assess whether patients were able to maintain their weight after gastric band removal or deflation and how they felt about gastric banding.

METHODS

A total of 41 patients (93% female, mean age 34.1 (SD 10.5) years) were included in this study: patients who had their band removed/deflated without further surgical intervention (group 1, n = 26) and those who later underwent a second bariatric operation (group 2, n = 15). We evaluated weight gain after band removal/during the time between band removal and second bariatric operation.

RESULTS

Of our patients, 31 (76%) suffered a complication (18 late pouch dilatations, six band infections, five band migrations, and two band leaks) requiring band removal. Ten patients wanted their band removed (six) or emptied (four). Mean time after band removal, when patients had neither a band nor a second bariatric operation, was 2.84 (SD 2.3) years. Five (12.2%) patients maintained their weight, four of whom experienced a learning effect; all others gained weight. Mean body mass index for both groups after the period without a band was 36.7 (SD 8.0) kg/m(2) (vs 29.4 (SD 7.0) at removal), and excess weight loss was 33.2% (SD 39.2; vs 69.8% (SD 32.9) at removal). Of our patients, 73% would not agree to gastric banding again. According to the bariatric analysis and reporting outcome system, long-term outcome of patients following band removal was a "failure" in 66% of patients.

CONCLUSIONS

Long-term outcome following band removal is unsatisfactory in many patients. Nevertheless, a minority of patients was able to maintain its weight loss.

Effect of bariatric surgery on both functional and structural measures of premature atherosclerosis

AIMS

To bridge the beneficial metabolic effects of pronounced weight loss on one side and the data on morbidity and mortality on the other side, we investigated the impact of profound weight loss on structural and functional markers of early atherosclerosis.

METHODS AND RESULTS

Thirty-seven obese adults were examined before and 18 months after bariatric surgery. Carotid intima-media thickness (CIMT), brachial flow-mediated dilation (FMD), nitroglycerine-mediated dilation, and abdominal fat distribution were assessed by high-resolution ultrasound. Surgery resulted in a body mass index decrease of 9.1 +/- 4.9 kg/m(2) with concomitant improvements in glucose and lipid metabolism. Carotid intima-media thickness diminished from 0.56 +/- 0.09 to 0.53 +/- 0.08 mm (n = 37; P = 0.004). Flow-mediated dilation improved from 5.81 +/- 3.25 to 9.01 +/- 2.93% (n = 25; P < 0.001). Both CIMT and FMD were associated with intra-abdominal fat diameter.

CONCLUSION

The present results demonstrate that bariatric surgery-induced diminution of visceral fat improves both functional and structural markers of early atherosclerosis, providing a link between the weight loss-associated improvements of traditional and non-traditional risk factors and the reduced long-term morbidity and mortality after bariatric surgery.

Retinol-binding protein 4, visceral fat, and the metabolic syndrome: effects of weight loss

Retinol-binding protein 4 (RBP-4) has been reported to be associated with visceral-fat accumulation and parameters of the metabolic syndrome (MetS). In this study, we investigated the relationship between RBP-4, visceral fat, and the MetS during pronounced weight loss after bariatric surgery. Thirty-six subjects were examined before and 2 years after surgery. Abdominal-fat distribution was determined by ultrasound, metabolic parameters, and serum RBP-4 levels by standard methods. After surgery BMI decreased by 9.07 kg/m(2), visceral-fat diameter (VFD) decreased by 60.6%, and RBP-4 serum levels by 16.6%. Change of RBP-4 levels was associated with reductions of waist (r = 0.364, P = 0.037), waist-to-hip ratio (WHR) (r = 0.415, P = 0.016), and VFD (r = 0.425, P = 0.010). MetS, as defined by International Diabetes Federation (IDF), was present in 19 patients at baseline and in nine patients at follow-up. Change in RBP-4 levels was the best predictor for the diagnosis of MetS at follow-up. In the subgroup without MetS at baseline, the decrease in RBP-4 levels (-28.1% vs. -6.3%, P = 0.020) and reduction in VFD (-66.9% vs. -55.0%, P = 0.038) were significantly greater compared to the subgroup with MetS. We demonstrate a marked decrease of RBP-4 levels after bariatric surgery, which correlates with reduction in visceral-fat mass. Furthermore, the extent of changes in RBP-4 levels differs according to the severity of the MetS.

Disappointing mid-term results after laparoscopic gastric banding in young patients

BACKGROUND

When gastric banding was introduced as a bariatric operation about 12 years previously, its early results were promising, with a low complication rate. Only a few long-term studies on this subject have been published. This study was performed to assess our results with laparoscopic gastric banding in young patients after<or=10 years of follow-up.

METHODS

From January 1996 to December 2000, a total of 41 patients (83% female, 17% male)<25 years old underwent laparoscopic gastric banding at our institution. The patient data were derived from the electronic patient data system, paper charts, and a telephone interview. Psychosocial changes were analyzed using the Moorehead-Ardelt/Bariatric Analysis and Reporting Outcome System questionnaire.

RESULTS

The mean preoperative body mass index was 44.26+/-6.53 kg/m2, with a mean excess weight of 65.22+/-20.48 kg. The body mass index after 1, 5, and 7 years was 31.50+/-7.38 kg/m2, 31.12+/-7.10 kg/m2, and 32.88+/-5.68 kg/m2, respectively. The mean excess weight loss after 1 year was 60.07%+/-25.33%, and after 5 and 7 years, it was 64.84%+/-27.45% and 57.48%+/-28.07%, respectively. An improvement in obesity-related co-morbidities was observed in nearly all patients. Of our patients, 52% had complications requiring reoperation (27% pouch dilation, 10% band leakage, 5% intragastral band migration, 5% perforation of either the esophagus or the stomach, and 5% port disconnection). According to Bariatric Analysis and Reporting Outcome System, the long-term outcome was regarded as a failure in 40%, fair in 4%, good in 28%, very good in 20%, and excellent in 8% of patients.

CONCLUSION

Our mid-term results were disappointing, with a high complication rate and many dissatisfied patients.

A-FABP--a biomarker associated with the metabolic syndrome and/or an indicator of weight change?

OBJECTIVE

Adipocyte fatty acid-binding protein (A-FABP) is a plasma biomarker recently associated with the metabolic syndrome. The aim of these studies was to investigate changes of A-FABP during profound weight loss induced by laparoscopic adjustable gastric banding (LAGB).

METHODS AND PROCEDURES

In study one, 29 severely obese female subjects were examined before and 1 year after surgical treatment. A subgroup of 10 patients was investigated in 3-month intervals. Metabolic parameters were determined using standard methods, and A-FABP was detected using a commercially available enzyme-linked immunosorbent assay.

RESULTS

Mean weight loss after 1 year was 24.9 kg (P < 0.001), mainly due to a decrease in fat mass. Metabolic parameters improved substantially. However, serum A-FABP remained stable. In study two, a subgroup of 10 patients was examined quarterly to determine the time course of A-FABP changes. Quarterly measurements of serum A-FABP were significantly higher than baseline levels with the highest A-FABP value after the first 3 months, where patients had highest weight loss.

DISCUSSION

Our results in study one show that A-FABP serum levels are positively associated with body weight and fat mass. However, 1 year after pronounced weight loss A-FABP levels remained unchanged. In study two, time course analyses revealed maximum increase of serum A-FABP in parallel to highest weight loss, which allows to suppose that A-FABP is not only a biomarker of the metabolic syndrome in the steady state, but also a marker of weight changes in dynamic situations.

Effect of pronounced weight loss on visceral fat, liver steatosis and adiponectin isoforms

BACKGROUND

Weight loss induced by bariatric surgery is an effective method to reverse obesity and comorbidities. The aim of this prospective weight loss study was to investigate changes of body fat distribution in relation to adiponectin and its isoforms and further to investigate the influence of both body fat distribution and adiponectin on the degree of liver steatosis.

DESIGN

Fifteen severely obese female patients (body mass index 43.1 +/- 4.1, mean age 34.5 +/- 8.6 years) were examined before and after surgical treatment. Grading of fatty liver disease and the subcutaneous and visceral fat diameters were determined by abdominal ultrasonography. Metabolic parameters were determined using standard methods; serum total adiponectin and its isoforms were detected by enzyme immuno assay (EIA).

RESULTS

Mean weight loss was 28.3 kg, which was mostly due to a loss in fat mass, accompanied by an increase in total adiponectin and the high molecular weight (HMW) adiponectin isoform. Visceral adipose tissue (VAT) diameter was highly correlated with liver steatosis, even more strongly than the parameters of liver function. In addition, liver steatosis correlated negatively with HMW adiponectin and binary logistic regression revealed that changes in fat mass, HMW adiponectin and alanine aminotransferase (ALT) were the best predictors for changes in the degree of hepatic steatosis.

CONCLUSIONS

Our results suggest that circulating HMW adiponectin is associated with both VAT and liver steatosis. In summary, the major findings were that the VAT diameter is highly correlated with liver steatosis, even stronger than the parameters of liver function and the association of HMW adiponectin with liver steatosis was better than with total adiponectin.

Effects of pronounced weight loss on adiponectin oligomer composition and metabolic parameters

OBJECTIVE

Adiponectin is an adipocytokine secreted into circulation in three isoforms. The aim of the study was to investigate changes of adiponectin isoforms during profound weight loss and its relation to anthropomorphometric and metabolic parameters.

RESEARCH METHODS AND PROCEDURES

Thirteen severely obese female subjects were examined before and 1 year after surgical treatment. Total adiponectin was determined by radioimmunosorbent assay, and oligomer composition was detected by nondenaturing Western blot.

RESULTS

BMI decreased substantially (p < 0.001), which was associated with an increase of total adiponectin from 12.9 +/- 5.9 to 14.3 +/- 6.1 microg/mL (p = 0.055). Medium molecular weight (MMW) adiponectin increased from 7.5 +/- 3.6 to 9.1 +/- 4.1 microg/mL (p = 0.009), whereas high (HMW) and low molecular weight adiponectin remained unchanged. Delta values of total adiponectin correlated significantly with Delta values of anthropometric parameters. Similar correlations were found for Delta values of MMW (Delta weight: r(2) = 0.4132, p = 0.0178; Delta BMI: r(2) = 0.3319, p = 0.0393; Delta fat mass: r(2) = 0.5202, p = 0.0054).

DISCUSSION

Thus, profound weight loss was associated with an increase in total adiponectin, which was mainly and consistently caused by increases in MMW adiponectin (p = 0.009). These changes result in a shift from low molecular weight to MMW and HMW adiponectin isoforms, which may be related to improvements in both anthropometric and metabolic parameters.

Surgery for morbid obesity

The prevalence of morbid obesity in the UK population is rising, bringing with it increased levels of cardiovascular disease, diabetes, arthritis and early mortality. The overall cost to the health service is high, and is set to increase over the coming decades as the overweight population ages. Dietary, lifestyle and pharmacological interventions offer at best reasonable, short-term weight reduction and often fail. Surgical intervention is a safe and effective means of delivering marked long-term weight reduction. This article compares and contrasts the options available for surgical treatment of morbid obesity based on a review of the current literature.

Gastric bypass surgery in the United States, 1998-2002

We assessed the prevalence of gastric bypass surgeries in the United States on the basis of data from the 1998 to 2002 National Hospital Discharge Survey. Between 1998 and 2002, rates (per 100,000 adults) increased significantly (P<.001): from 7.0 to 38.6. This observed increase in the rate of gastric bypass surgery for the treatment of obesity may be attributed in part to improvements in surgical technique, improved patient outcomes, and increased popularity of this procedure.

Effect of pronounced weight loss on the nontraditional cardiovascular risk marker matrix metalloproteinase-9 in middle-aged morbidly obese women

OBJECTIVE

Obesity is associated with increased morbidity and mortality from atherosclerotic disease. Nontraditional cardiovascular risk factors such as C-reactive protein (CRP) and interleukin-6 (IL-6) are elevated in obese subjects and weight loss is associated with an attenuation of these risk factors. Matrix metalloproteinase-9 (MMP-9) has been linked to plaque rupture, and is, thus, a candidate marker of future myocardial events. The aim of this study was to determine the influence of weight loss on MMP-9 plasma concentrations.

METHODS AND RESULTS

CRP, IL-6 and MMP-9 were analyzed from samples of 45 morbidly obese, middle-aged women before gastric banding and 1 y postsurgical treatment in this prospective study. The body mass index (BMI) of subjects decreased from 42.5+/-4.9 to 32.3+/-5.3 kg/m(2) 1 y after gastric banding. In parallel, both MMP-9 and CRP were reduced by 23 and 41%, respectively. A positive relationship was found between BMI and MMP-9 (r=0.312, P<0.05), and between CRP and IL-6 (r=0.508, P<0.05), whereas no correlation was found between CRP and MMP-9.

CONCLUSIONS

We conclude that weight loss is associated with a pronounced decrease in the nontraditional cardiovascular risk markers MMP-9 and CRP, which could indicate future beneficial effects of weight loss on the cardiovascular risk in weight loosing subjects.

Laparoscopic gastric banding: safe and modestly successful

BACKGROUND

Obesity is an increasing problem in Australia. It is defined as a body mass index (BMI) >30 kg/m(2). It is associated with a number of significant medical conditions, as well as psychological morbidity related to poor body image and the social stigma of obesity. Conservative management is rarely successful in patients with morbid obesity and bariatric surgery is an alternative more likely to produce sustained results.

METHODS

To compare the initial results of the Lap-Band (Inamed Health, Santa Barbara, CA, USA) procedure when performed by experienced general laparoscopic surgeons, new to the procedure and those achieved by dedicated bariatric practitioners.

RESULTS

The results of the present study showed forty-seven per cent excess weight lost at 2 years, 49% excess BMI lost at 2 years. Reoperation rate for band removal, prolapse/slippage was 25.3%.

CONCLUSIONS

Acceptable results with Lap-Band are technically achievable by experienced laparoscopic surgeons with a low morbidity and mortality. The results of the present study are inferior to those reported by dedicated bariatric practices who have performed large numbers of this operation. The rate of band slippage was unacceptably high and there was a significant problem with patients being lost to follow up. Possible reasons for this are discussed.

Prevention of catheter disconnection after laparoscopic adjustable gastric banding

In a consecutive series of 138 laparoscopic adjustable gastric bandings (LAGB) we observed disconnection of the gastric band catheter at the site of the port connector in 17 patients. During operative revision we established a new port position with a minimal distance of 10 cm between the connector and the entrance of the catheter to the abdominal cavity. Using this technique no complications and no catheter disruptions occurred during a median followup period of 25 months.

Assessment and management of the obese patient

BACKGROUND

The perioperative care of the clinically severe obese patient presents numerous unique challenges. As an increasing number of people in North America fall into the category of the clinically severe obese, the care of these patients will become increasingly more challenging and prevalent. These patients have unique issues with regards to cardiovascular, pulmonary, and thromboembolic complications. In addition, hospital equipment must be able to accommodate the body habitus of this population.

MATERIALS AND METHODS

A Medline search using "perioperative care," "morbid obesity," "thromboembolic complications," "preoperative screening," and "postoperative care" as key words was performed for English-language articles. Further references were obtained through cross-referencing the bibliography cited in each work.

DISCUSSION

The management of the clinically severe obese patient requires meticulous preoperative, perioperative, and postoperative care. Careful preoperative planning is essential before taking the patient to the operating room. To have excellent outcomes, a multidisciplinary approach, including the primary care physician, anesthesiologist, surgeon, nursing staff, and social work, is necessary.

Surgical revision after failure of laparoscopic adjustable gastric banding

BACKGROUND

This paper reports the outcome of surgical revision for complications following laparoscopic placement of an adjustable silicone gastric band (AGB) to treat morbid obesity.

METHODS

Seventy-three (19.1 per cent) of 382 patients who underwent laparoscopic AGB placement between January 1996 and March 2001 presented with complications within 6 years after operation. Revision was carried out with the intention of reinstating the functional device in all patients.

RESULTS

Successful surgical revision or gradual balloon deflation was performed in 53 patients (29 port-related complications, 14 pouch dilatations, 12 band leakages, three oesophageal dilatations, two symptomatic hernias, one late migration, one intracerebral bleed). Of these patients, 51 (96.2 per cent) had a successful outcome according to the Bariatric Analysis and Reporting Outcome System following significant additional postinterventional weight loss. AGB removal was carried out in 20 patients (13 early or late migrations, five pouch dilatations, three port-related complications, two psychiatric disorders, one band leakage). The final failure rate for complicated AGB procedures was 30.1 per cent.

CONCLUSION

AGB placement is associated with a variety of complications. In most cases surgical complications can be treated with minimally invasive surgery, which should allow further weight loss and improvement of quality of life during long-term follow-up. Alternative bariatric procedures should be reserved for patients with poor outcome after surgical revision of the AGB.

Current status of bariatric surgery in the treatment of type 2 diabetes

Bariatric surgery (from the Greek words baros meaning 'weight' and iatrikos 'the art of healing') is a rapidly evolving branch of surgical science. The aim is to induce major weight loss in those whose obesity places them at high risk of serious health problems. In an attempt to balance the risks of surgery against the benefits of weight loss, bariatric operations are currently performed only in the morbidly obese, or those with a body mass index (BMI) > 35 kgm(-2) who already have developed comorbidity such as type 2 diabetes. Although weight loss is beneficial for obese patients with diabetes, current medical treatment for obesity is difficult. In contrast, observational studies show a major impact of bariatric surgery on diabetes, raising the question whether this approach should be used more widely to treat diabetes in obese patients? If bariatric surgery were shown to be the best way to treat diabetes in obese subjects the implications for health services would be wide-ranging. Bariatric surgery leads to withdrawal of diabetic treatment in about 60% or more of patients, and reductions of therapy for many others. Although data on bariatric surgery in subjects with diabetes are provocative, most studies have been uncontrolled or flawed in other ways. Most importantly, bariatric surgery has not yet been compared against standard medical treatment for diabetes in randomized controlled trials with diabetes-specific endpoints in all relevant patient groups. Potential indications for bariatric surgery are discussed, and the unanswered questions that need to be addressed by clinical trials are summarized. Although small numbers of patients may be interested in bariatric surgery for type 2 diabetes, current data are insufficient to endorse its wide scale use for this indication. Until essential studies are undertaken the role and economics of bariatric surgery in the diabetic clinic will remain uncertain.

Metabolic and psychosocial effects of minimal invasive gastric banding for morbid obesity

Obesity is considered a primary risk factor for cardiovascular disease and related mortality. The current study aimed to investigate the efficacy of minimal invasive gastric banding (GB) surgery for reducing caloric intake in morbid obesity, and to analyze the effects of weight loss on body composition and metabolic and psychosocial outcomes. Twenty-six adult severely obese patients (mean body mass index [BMI], 48.1 kg/m(2); range, 42 to 56) underwent adjustable silicone laparoscopic GB. Nine additional obese patients who declined surgery were treated with metformin (2 g daily) and served as a small additional group (BMI, 50.5 kg/m(2); range, 41 to 68). Presurgery and 17 +/- 2.2 months postoperatively, body composition (fat mass [FM], lean body mass [LBM], body water) and serum parameters (lipids, glucose, thyrotropin-stimulating hormone [TSH]) were determined. Quality of life (QoL) was evaluated by a standardized self-rating questionnaire (Short Form-36 [SF-36]), and supplemented by measures of physical complaints and psychological distress. After GB, weight loss was 21 +/- 14.9 kg (14%, P <.001). It was associated with a decrease in FM by 14 +/- 8.6 kg (18%, P <.001), LBM by 4 +/- 2.7 kg (5%, P <.001), body water by 4 +/- 3.4 L (7%, P <.01), systolic blood pressure by 16 +/- 26.3 mm Hg (10%, P <.05), total cholesterol by 0.69 +/- 1.29 mmol/L (12%, P <.05), and low-density lipoprotein cholesterol (LDL-C) by 0.38 +/- 0.39 mmol/L (10%, P <.05). Highly significant interactions between surgery and time were noted for weight (P <.005), BMI (P <.005), and FM (P <.007, analysis of variance [ANOVA]). Preoperatively, 14 of 26 patients (54%) had high fasting blood sugar levels (type 2 diabetics) and 11 (42%) had impaired glucose tolerance, whereas postoperatively, for baseline glucose levels a trend to decrease was noted. Neither malabsorption nor anemia was observed. QoL improved after GB; in particular, physical functioning and well being increased (P <.01), and somatic complaints (eg, dyspnea and heart complaints, pain in legs and arms) markedly decreased (P =.008). In the metformin group, neither relevant weight loss nor a significant decrease of biochemical values was observed. Minimal invasive GB is a successful therapeutic tool for reducing FM in morbidly obese patients. Weight loss resulted in improved metabolic parameters, suggesting a lowered atherogenic risk.

The management of the obese diabetic patient

The prevalence of obesity and diabetes is increasing in the United States and worldwide. These diseases are predicted to explode to epidemic proportions, unless appropriate counteractive measures are taken. Several large studies (DCCT, UKPDS, Kumamoto) clearly showed that intensive glycemic control in the diabetic patient reduced microvascular complications and improved mortality. Despite this, the NHANES III showed that only 50% of diabetics have been able to achieve a HgbAic level that is less than 7%; this suggests the need for a re-evaluation of our approach to these patients. The management of the obese diabetic patient involves glycemic control and weight reduction. These goals are particularly difficult to achieve in the obese diabetic patient because progressive beta-cell dysfunction and increasing insulin resistance necessitates the administration of increasingly higher dosages of insulin, which, in turn, promotes weight gain. A vicious cycle may ensue. Lifestyle modifications with diet and exercise are an essential part of the management of the obese diabetic patient. These measures alone are often insufficient and concomitant pharmacologic therapy is usually required to achieve glycemic and weight control. Oral agents that improve glycemia, decrease insulin resistance, and limit weight gain are desirable. Because of the progressive nature of diabetes, glycemic control with monotherapy often deteriorates over time, which necessitates the addition of other pharmacologic agents, including insulin. When insulin therapy is required in the treatment of the obese diabetic patient, combinations with oral agents that have been shown to minimize the amount of exogenous insulin that is required, may minimize weight gain. In addition, the obese diabetic patient who is poorly controlled with maximum oral hypoglycemic therapy may benefit from weight-reducing agents, such as sibutramine or orlistat. The introduction of these agents at other points in the management of the obese diabetic patients have been successful. Finally, for the severely obese diabetic patient, bariatric surgery may be the only effective treatment. Gastric bypass has been unequivocally shown to produce significant weight loss and improve glycemic control on a long-term basis in the obese diabetic patient. It is recommended that physicians avail themselves of all of these strategies in the management of the obese patient who has type 2 diabetes.

Laparoscopic gastric banding

INTRODUCTION

Laparoscopic gastric banding (LGB) is currently the most popular purely restrictive bariatric operation in Europe and many other countries. It has a low operative morbidity, but is associated with a substantial late complication rate. Many late complications have been attributed to technical errors or to the learning curve. The aim of this paper is to present our results with gastric banding after the learning curve in order to disclose the true incidence of long-term complications.

METHODS

LGB was introduced in our department in December 1995. Thirty patients were operated on until June 1997 using the early banding technique (band within the lesser sac), at which time the surgical technique was slightly modified in order to place the band above the lesser sac. Then another 300 patients underwent LGB using either the Lapband or the SAGB system. This report focuses on the latter patients. All the data were collected prospectively.

RESULTS

The series includes 300 patients (257 women and 43 men) with a mean age of 38.3 years (19-64). The mean initial weight was 119.2 kg (57-179), initial body mass index (BMI) was 43.3 kg/m2 (21-64), and initial excess weight was 96.5% (0-191). The mean duration of surgery was 90 min, decreasing over time to a mean of 75 min for the last 50 cases. Early overall morbidity was 6.6%. Major complications occurred in 7 patients (2.3%). Excess weight loss (EWL) was at least 50% in 66% of the patients after 2 years, averaging 60%, with no substantial change until 4 years, and the BMI stabilized between 30 and 31 kg/m2. Forty-nine patients developed a total of 52 long-term complications, of which 23 (7.6%) were related only to the port or catheter. Band erosion occurred in 17 (5.6%), pouch dilatation with slippage in 8 (2.6%), and infection in 4 (1.3%) patients. Fifty-five reoperations were necessary. Twenty-five of these were related only to the port. The band was removed from 26 (9%) patients, of whom 17 were converted to Roux-en-Y gastric bypass.

CONCLUSIONS

LGB gives satisfactory results in terms of weight loss in about two-thirds of the patients. Even beyond the learning curve, the long-term morbidity is not negligible, but is acceptable compared to other procedures such as vertical banded gastroplasty. Conversion to gastric bypass is possible when complications occur and can be performed when the band is removed in most cases.

[Gastroplasty: complications and their prevention]

Bariatric surgery is now frequently proposed for the treatment of morbid or complicated obesity since the introduction of minimally invasive laparoscopic anti-obesity operations such as the adjustable silicone gastric binding gastroplasty. However this reversible procedure in not always as safe as presumed and the results in weight loss may be sometimes disappointing. Side effects are common and early or late complications occured in more than 20% out of the patients. They are favoured by post operative eating disorders. Nutritional consequences are probably underestimated and are not limited to uncomfortable digestive symptoms. Some deficiencies in micronutriments have been described. The worsening of previous eating disorders or psychosocial abnormalities are not seldom. Gastroplasty is not an harmless procedure. A good selection in patients, a regular follow up, nutritional advices and psychosocial management by a multidisciplinar team are required to reduce complications after gastroplasty.

Is it necessary to deflate the adjustable gastric band for subsequent operations?

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) is an effective method in the treatment of morbid obesity. However, it is unknown, whether deflating the gastric band before operations under general anesthesia is necessary to avoid complications such as nausea, vomiting, respiratory complications, and weight regain.

METHODS

Between January 1996 and June 2001, we performed LAGB on 408 patients at the University Hospital of Innsbruck. Of these patients, we identified 68 (16.7%) patients who were to undergo subsequent unrelated general, reconstructive, vascular, or orthopedic procedures. These patients were prospectively randomized into two groups: group 1 (n = 32) preoperative deflation of the adjustable band system and group 2 (n = 36) without preoperative deflation of the adjustable band system.

RESULTS

There were no anesthetic or perioperative band-related complications in either group 1 or group 2. There were two reoperations necessary due to surgical complications unrelated to the gastric band.

CONCLUSIONS

Operations after adjustable gastric banding can be safely performed without deflating the adjustable system.

Markers of chronic inflammation and obesity: a prospective study on the reversibility of this association in middle-aged women undergoing weight loss by surgical intervention

BACKGROUND

Human adipose tissue expresses and releases proinflammatory cytokines and these measures of chronic inflammation have recently been associated with obesity.

HYPOTHESIS

To test whether the proinflammatory state is reversible in subjects undergoing weight loss by surgical measures.

SUBJECTS AND METHODS

Twenty morbidly obese women participated in this prospective study. Subjects were examined for fat mass, high-sensitive C-reactive protein (hs-CRP), interleukin 6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) before and 1 y after Swedish adjustable gastric banding.

RESULTS

Anthropometric measures displayed a significant reduction of the body mass index (BMI) from 41.6+/-5.4 to 30.8+/-6.1 kg/m(2) and the fat mass from 53.9+/-10.3 to 29.8+/-12.1 kg (mean+/-s.d.). Hs-CRP levels decreased significantly from 1.33+/-1.21 mg/dl in pre-gastric banding subjects to 0.40+/-0.61 mg/dl in post-gastric banding subjects, respectively. IL-6 and TNF-alpha levels did not differ significantly between pre- and post-gastric banding subjects.

CONCLUSIONS

We speculate that in these patients the marked reduction in C-reactive protein might be beneficial in reducing their cardiovascular risk and is not solely mediated by IL-6 and TNF-alpha.