Upper Gastrointestinal Function in Morbidly Obese Adolescents Before and 6 Months After Gastric Banding

BACKGROUND

The effects of laparoscopic adjustable gastric band (LAGB) placement on upper gastrointestinal tract function in obese adolescents are unknown. Therefore, our aim was to determine the short-term effects of LAGB on esophageal motility, gastroesophageal reflux, gastric emptying, appetite-regulatory hormones, and perceptions of post-prandial hunger and fullness.

METHODS

This study was part of a prospective cohort study (March 2009-December 2015) in one tertiary referral hospital. The study included obese adolescents (14-18 years) with a body mass index (BMI) > 40 (or ≥ 35 with comorbidities). Gastric emptying was assessed by ¹³C-octanoic acid breath test, pharyngeal, and esophageal motor function by high-resolution manometry with impedance (HRIM), and appetite and other perceptions using 100-mm visual analogue scales. Dysphagia symptoms were scored using a Dakkak questionnaire. Data were compared pre- and post-LAGB placement and at a 6-month follow-up.

RESULTS

Based upon analysis of 15 adolescents, at the 6-month follow-up, LAGB placement: (i) led to a significant reduction in weight and BMI; (ii) increased fullness and decreased hunger post-meal; (iii) increased symptoms of dysphagia after solid food; and, despite these effects, (iv) caused little or no changes to appetite hormones, while (v) effects on gastric emptying, esophageal motility, esophageal bolus transport, and esophageal emptying were not significant.

CONCLUSION

In adolescents, LAGB improved BMI and altered the sensitivity to nutrients without significant effects on upper gastrointestinal tract physiology at the 6-month follow-up.

Evaluation of the Swedish adjustable gastric band VC (SAGB-VC) in an Australian population: early results

BACKGROUND

The Swedish adjustable gastric band VC (SAGB-VC) has been in use in Australia since 2007. We evaluated its efficacy and safety.

METHODS

We retrospectively analyzed the prospective clinical data of patients who received the implant between November 2007 and June 2009 at 3 Australian bariatric centres.

RESULTS

In all, 1176 patients (mean age 45.9 [standard deviation (SD) 12.3] yr, mean body mass index 43.4 [SD 7.6]) received the SAGB-VC. At a mean follow-up of 11 (SD 3) months, weight reduced by a mean of 18.4 (SD 11.1) kg with an excess weight loss of 37.8% (SD 19.9%). Body mass index decreased (from mean 43.4 [SD 7.7] to mean 36.7 [SD 6.5], p < 0.001). Type 2 diabetes (T2DM) was reported in 167 patients and hypertension in 373. Improvement occurred in 73.5% of patients with T2DM and 31% with hypertension, with patient-reported reduction or cessation of medication. Metabolic syndrome indices improved during follow-up: high-density lipoprotein cholesterol (mean 1.3 [SD 0.3] v. mean 1.4 [SD 0.3] mmol/L, p < 0.001), triglycerides (mean 1.6 [SD 0.8] v. mean 1.3 [SD 0.7] mmol/L, p < 0.001), waist circumference (men 141 [SD 103] to 121 [SD 15] cm, women 117 [SD 14] to 105 [SD 14] cm, both p < 0.001), C-reactive protein (90.5 [SD 75.2] v. 53.3 [SD 61.9] nmol/L, p < 0.001). The complication rate was 4.2%.

CONCLUSION

The SAGB-VC is safe and effective for treating obesity and its comorbidities. The results are reproducible in separate Australian centres and consistent with published literature.

Vagal blocking improves glycemic control and elevated blood pressure in obese subjects with type 2 diabetes mellitus

BACKGROUND

An active device that downregulates abdominal vagal signalling has resulted in significant weight loss in feasibility studies.

OBJECTIVE

To prospectively evaluate the effect of intermittent vagal blocking (VBLOC) on weight loss, glycemic control, and blood pressure (BP) in obese subjects with DM2.

METHODS

Twenty-eight subjects were implanted with a VBLOC device (Maestro Rechargeable System) at 5 centers in an open-label study. Effects on weight loss, HbA1c, fasting blood glucose, and BP were evaluated at 1 week to 12 months.

RESULTS

26 subjects (17 females/9 males, 51 ± 2 years, BMI 37 ± 1 kg/m(2), mean ± SEM) completed 12 months followup. One serious adverse event (pain at implant site) was easily resolved. At 1 week and 12 months, mean excess weight loss percentages (% EWL) were 9 ± 1% and 25 ± 4% (P < 0.0001), and HbA1c declined by 0.3 ± 0.1% and 1.0 ± 0.2% (P = 0.02, baseline 7.8 ± 0.2%). In DM2 subjects with elevated BP (n = 15), mean arterial pressure reduced by 7 ± 3 mmHg and 8 ± 3 mmHg (P = 0.04, baseline 100 ± 2 mmHg) at 1 week and 12 months. All subjects MAP decreased by 3 ± 2 mmHg (baseline 95 ± 2 mmHg) at 12 months.

CONCLUSIONS

VBLOC was safe in obese DM2 subjects and associated with meaningful weight loss, early and sustained improvements in HbA1c, and reductions in BP in hypertensive DM2 subjects. This trial is registered with ClinicalTrials.gov NCT00555958.

International multicenter study of safety and effectiveness of Swedish Adjustable Gastric Band in 1-, 3-, and 5-year follow-up cohorts

BACKGROUND

No long-term, international, multicenter studies of the effectiveness and safety of the SAGB in morbid obesity have been previously published. The objective of this study was to assess the effectiveness and safety of the Swedish Adjustable Gastric Band (SAGB) at 6 bariatric centers in Australia, Europe, and Brazil, with < or =5 years of follow-up; the effect on patient covariates; and changes in co-morbidity.

METHODS

A 2-phase study design was used, involving both retrospective and prospective data. SAGB was implanted by way of the pars flaccida 1, 3, and 5 years previously. The retrospective phase entailed a review of the records. The prospective phase included a subset of eligible patients who agreed to undergo additional clinical assessments. The percentage of excess weight loss (%EWL), patient level predictors, change in co-morbidities, and complications were analyzed.

RESULTS

A total of 481 patients in 3 mutually exclusive follow-up cohorts (1 yr, n = 200; 3 yr, n = 184; 5 yr, n = 97) participated in the present study. Of these 481 patients, 339 (1 yr, n = 139; 3 yr, n = 131; 5 yr, n = 69) underwent prospective evaluations. The mean %EWL was 43.5% + or - 21.8%, 57.7% + or - 25.9%, and 49.8% + or - 27.6% and the mean change in body mass index was -7.64, -10.75, and -9.52 in the 1-, 3-, and 5-year cohorts, respectively (P <.001). Gender and age did not predict the %EWL; however, a greater preoperative body mass index was inversely related to the %EWL. Longer postimplantation times were associated with greater improvement in co-morbidities and with greater frequencies of reoperation. Fewer than 15% of the patients in the 5-year cohort had undergone band removal and 10% required band revisions. No fatal or life-threatening complications occurred.

CONCLUSION

SAGB is safe and effective in inducing weight loss and improvement of co-morbidities in morbidly obese patients at international bariatric centers at 1, 3, and 5 years postoperatively.

Associates of change in liver fat content in the morbidly obese after laparoscopic gastric banding surgery

AIM

Hepatic steatosis affects up to 30% of the population. After weight loss, monitoring of the change in hepatic steatosis is not routinely performed. This study aimed to define the closest associates of change in liver fat content in a population of obese females following laparoscopic gastric banding surgery.

METHODS

Before and 3 months after surgery, proton magnetic resonance spectroscopy and magnetic resonance imaging were used to estimate the amount of lipid contained within the liver and abdominal subcutaneous and visceral compartments of 29 obese [mean body mass index (BMI) 39 +/- 5 kg/m(2)], non-diabetic women aged between 20 and 62 years. Liver enzymes, fasting plasma glucose and insulin were also measured as well as body weight, BMI and waist circumference. Insulin sensitivity was estimated using homeostasis model assessment insulin resistance index.

RESULTS

Significant reductions occurred in body weight (p < 0.001), abdominal fat volumes (p < 0.001) and liver fat (p = 0.037) 3 months after surgery. Change in liver fat content more closely associated with change in serum gamma-glutamyl transferase (GGT; r = 0.71, p < 0.001) than with changes in weight (r = 0.10, p = 0.612) and waist circumference (r = 0.15, p = 0.468).

CONCLUSIONS

Our findings suggest that obese non-diabetic female patients who have undergone significant weight loss over 3 months can be better assessed for the regression of excess liver fat content by monitoring changes in serum GGT levels rather than changes in simple anthropometry.

Intra-abdominal vagal blocking (VBLOC therapy): clinical results with a new implantable medical device

BACKGROUND

A new medical device uses high-frequency electrical algorithms to create intermittent vagal blocking (VBLOC therapy). The aim is to assess the effects of vagal blocking on excess weight loss (EWL), safety, dietary intake, and vagal function.

METHODS

An open-label, 3-center study was conducted in obese subjects (body mass index [BMI] 35-50 kg/m(2)). Electrodes were implanted laparoscopically on both vagi near the esophagogastric junction to provide electrical block. Patients were followed for 6 months for body weight, safety, electrocardiogram, dietary intake, satiation, satiety, and plasma pancreatic polypeptide (PP) response to sham feeding. To specifically assess device effects alone, no diet or exercise programs were instituted.

RESULTS

Thirty-one patients (mean BMI, 41.2 +/- 1.4 kg/m(2)) received the device. Mean EWL at 4 and 12 weeks and 6 months after implant was 7.5%, 11.6%, and 14.2%, respectively (all P < .001); 25% of patients lost >25% EWL at 6 months (maximum, 36.8%). There were no deaths or device-related serious adverse events (AEs). Calorie intake decreased by >30% at 4 and 12 weeks and 6 months (all P <or= .01), with earlier satiation (P < .001) and reduced hunger (P = .005). After 12 weeks, plasma PP responses were suppressed (20 +/- 7 vs 42 +/- 19 pg/mL). Average percent EWL in patients with PP response <25 pg/mL was double that with PP response >25 pg/mL (P = .02). Three patients had serious AEs that required brief hospitalization, 1 each for lower respiratory tract, subcutaneous implant site seroma, and Clostridium difficile diarrhea.

CONCLUSIONS

Intermittent, intra-abdominal vagal blocking is associated with significant EWL and a desirable safety profile.

A simple scoring system for predicting bile duct stones in patients with cholelithiasis

A means of accurately predicting the presence of stones in the bile duct in patients undergoing laparoscopic cholecystectomy for gallbladder stones is lacking. With the use of a three-stage analysis, a predictive score was developed from seven common parameters. Initially the score was formulated by using data from a retrospective series of patients undergoing laparoscopic cholecystectomy; the system was then tested prospectively over a 1-year period in patients undergoing laparoscopic cholecystectomy for gallbladder stones. This simple scoring system demonstrated an ability to predict bile duct stones with a sensitivity in excess of 70%. The use of such a score may allow the development of preoperative strategies for treating patients undergoing laparoscopic cholecystectomy.

Minimally invasive management of bile leak after laparoscopic cholecystectomy

BACKGROUND

Bile leakage is an uncommon complication of cholecystectomy.The bile may originate from the gallbladder bed, the cystic duct or rarely from injury to a major bile duct.This study aims to evaluate the efficacy of minimal access endoscopic and percutaneous techniques in treating symptomatic bile leak.

PATIENTS AND METHODS

Twenty-one patients with symptomatic bile leak following laparoscopic cholecystectomy underwent assessment of the extent of the bile leak via ultrasound/CT and ERCP. Following diagnosis, the patients were treated by sphincterotomy and biliary drainage and, if necessary, percutaneous drainage of the bile collection.

RESULTS

Only one patient required primary surgical treatment following diagnosis of a major duct injury.The other 20 were treated by a combination of sphincterotomy (including a stent in most) plus percutaneous drainage in six. In 19 of 20, this minimal access approach stopped the leak.

DISCUSSION

Most patients who present with bile leakage after cholecystectomy can be managed successfully by means of ERCP with percutaneous drainage of any large bile collection.

What are the risks of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography?

BACKGROUND

Diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) has been practised widely over the last 20 years, and it has revolutionized the diagnosis and management of biliary and pancreatic conditions. More recently newer techniques (magnetic resonance imaging) for diagnosis and therapy (laparoscopic biliary surgery) have evolved. The present paper evaluates the risks of ERCP procedures in a modern setting.

METHODS

A prospective audit of all ERCP carried out by a single unit across two campuses over 12 months was undertaken. All procedures were included and predetermined morbidity criteria were recorded and evaluated by independent observers who did not perform the procedures.

RESULTS

During this period 372 procedures were performed. A total of 9.4% of procedures failed to achieve the preprocedure-stated goal. There were five deaths (30-day mortality of 1.3%) and in 16 patients complications were recorded (morbidity of 4.3%). Two clinical and two technical factors were shown to be associated with the morbidity and mortality by multiple logistic regression analysis: diagnosis of sphincter of Oddi dysfunction; presence of jaundice; need to perform percutaneous transhepatic drainage of an obstructed biliary system after a failed endoscopic approach; and multiple ERCP.

CONCLUSIONS

These results compare favourably with results from other reported series and serve to illustrate the relative safety of diagnostic and therapeutic ERCP.

Early results of laparoscopic swedish adjustable gastric banding for morbid obesity

AIMS: Gastric bypass and vertical banded gastroplasty (VBG) are currently the most commonly performed bariatric procedures but neither are ideal. The results of the first 56 patients who had laparoscopic Swedish adjustable gastric banding (SAGB) are presented. METHODS: All patients referred for bariatric surgery were considered for SAGB. Each was given the alternative of gastric bypass. Patients with a body mass index of less than 35, large hiatus hernia, under 18 years of age, gastric pathology and significant psychiatric illness were excluded. Preoperative gastroscopy, ultrasonographic examination of the gallbladder and specialist anaesthetic assessment were arranged. All but five patients had attempted laparoscopic procedures. Patients were discharged when they were mobile and could tolerate 1500 ml fluid per day. Patients were given a liquidized diet for 6 weeks. Assessments were made at 6 weeks and 3, 6, 9 and 12 months. RESULTS: Some 56 consecutive patients were followed for up to 12 months. The conversion rate fell from 52 per cent for the first 25 patients to 20 per cent for the last 20. Conversion rates were higher in men and in superobese patients. The duration of a laparoscopic operation fell significantly with experience but was still significantly longer than that of an open procedure (P < 0.004). The length of hospital stay was significantly shorter for laparoscopic procedures (P < 0.001). There was no death and little morbidity. Two bands had to be removed (easily) by open surgery, one for infection and one for a recurrence of gastric herniation. The mean excess weight loss was 60 per cent at 12 months. Greater than 50 per cent of excess body-weight was lost by 48 per cent of patients at 6 months and 69 per cent at 12 months. Band adjustments in most patients achieved further weight loss to compensate for late pouch dilatation. Most failures were in patients who failed to attend. CONCLUSION: SAGB appears to have many advantages over gastric bypass and VBG; it avoids stapling the stomach, should not cause any malabsorption, can be performed laparoscopically, is adjustable, is more readily reversed (if necessary) and, therefore, has the potential for lower associated morbidity and mortality rates. In terms of excess weight loss, the early results are certainly as good, if not better, than those of gastric bypass and VBG.

Comparison of cefotaxime plus metronidazole versus cefoxitin for prevention of wound infection after abdominal surgery

In a randomized prospective stratified trial consisting of 1010 patients undergoing abdominal surgery involving the viscera, the efficacy of cefotaxime plus metronidazole was compared to cefoxitin for preventing wound infection. The efficacy of a single dose of antibiotics versus three doses over 24 hours was also evaluated. This study demonstrated that a single-dose antibiotic regimen was as effective as a multiple-dose regimen in the prophylaxis of wound infections following abdominal surgery. In addition it demonstrated that the cefotaxime plus metronidazole regimen is comparable to that of cefoxitin and is more cost-effective. It is concluded that a single dose of cefotaxime plus metronidazole provides effective prophylaxis against postoperative wound infections following abdominal surgery.