Treatment of morbid obesity with the Swedish adjustable gastric band (SAGB): complication rate during a 12-month follow-up period

BACKGROUND

The Swedish adjustable gastric band (SAGB) is used to treat morbid obesity. However, no quantitative data are available describing the follow-up of these patients with respect to the frequency and the complication rate of inflating and deflating the adjustable system.

METHODS

We prospectively investigated 207 morbidly obese patients. All patients completed 12 months of follow-up and were seen in intervals of 1 to 3 months on an outpatient basis.

RESULTS

A total of 207 patients had 1692 consultations (8.3 +/- 2.4 consultations per patient per year [mean +/- SD]), 920 port-a-cath punctions (4.6 +/- 2.0), 820 inflations (4.1 +/- 1.6), and 100 deflations (1.4 +/- 0.6). Complications related to the port-a-cath (n = 6, 2.9% of all patients) were 1 leakage of the tube (0.5%), 2 disconnections of the connecting tube (1.0%), and 3 reimplantations of the port-a-cath as a result of discomfort (1.4%). Complications related to the SAGB (n = 10, 4.8%) were 6 leakages of the band (2.9%), 2 penetrations (1.0%), 1 intraoperative perforation of the esophagus (0.5%), and 1 dystopically implanted SAGB (0.5%). Additionally, 9 minor early postoperative wound infections (4.3%) were recorded.

CONCLUSIONS

Follow-up can be safely performed on an outpatient basis after implantation of a SAGB without infectious and other minor complications directly linked to the filling procedure.

Is bariatric surgery worth its costs?

Formal economic evaluations of obesity surgery have not been reported in the medical literature to date. In this article, we briefly review the most important types of health economic evaluations, namely cost-effectiveness analysis, cost-utility analysis, and cost-benefit analysis. Bariatric surgery has the potential to substantially impact quality of life, morbidity, and mortality costs in patients with morbid obesity. Health economic studies that include these effects are needed.

Swedish adjustable gastric band (SAGB)-distal gastric bypass: a new variant of an old technique in the treatment of superobesity and failed band restriction

BACKGROUND

Dissatisfied with vertical banded gastroplasty in superobese patients, the authors adopted Salmon's gastroplasty/distal gastric bypass (DGBP) in 1995. When the Swedish adjustable gastric band (SAGB) became available in Switzerland, the authors started using that device instead of the gastroplasty because implanting a SAGB is much easier and gastric restriction with a SAGB is adjustable to the patients' individual demands.

METHODS

The authors evaluated 40 consecutive patients with SAGB-DGBP (27 primary and 13 secondary operations) for weight loss and complications, and compared weight loss with that obtained by SAGB alone. The mean initial body weight was 156.6 kg in women and 188.1 kg in men for primary and 108.2 kg/147.0 kg for secondary indications, respectively. The band was placed in a high position without tunneling sutures, and DGBP was done with a 50- to 60-cm common channel and a 60- to 80-cm biliopancreatic limb.

RESULTS

Weight loss at 1 year was 33.3% of initial body weight for primary operations. Weight loss was significantly more than with SAGB-alone cases. Complications were as follows: no death, no slipping or pouch dilatation; one marginal ulcer, one splenectomy, four cholecystectomies, one Roux-en-O reconstruction, two band leaks, eight port-related reoperations. Iron or vitamin deficiencies occurred in 75% of patients, with one case of transient protein malnutrition and one of intermittent diarrhea.

CONCLUSIONS

The SAGB as gastric restriction in combination with DGBP can be implanted easily. The new-generation SAGB is safe, but longer follow-up is necessary. SAGB-DGBP is more efficient than SAGB alone for weight reduction. It is too early to recommend banded DGBP as a primary procedure. However, in cases of insufficient weight loss after placement of an adjustable band, adding a DGBP without removing the band is an option. Follow-up by a specialized team is mandatory.

Actigraphic assessment of sleep in insomnia: application of the Actigraph Data Analysis Software (ADAS)

The usefulness of the actigraph methodology has been demonstrated in normal individuals. However, the validity of actigraphy has been questioned in insomnia patients because of the considerable measurement error that has been reported between actigraphy (ACT) and polysomnography (PSG). Two independent investigations have reported errors of 48 and 49 min in total sleep time between ACT and PSG. With a new scoring method called the Actigraph Data Analysis Software, a reanalysis of one of these studies was conducted. Based on this reanalysis, we have obtained a measurement error of only 25 min between the two methods. This finding may be an indication of the advantage of this new scoring method. A strong correlation coefficient (r = 0.82, p < 0.0001) was noted between ACT and PSG for total sleep time, thus suggesting a high degree of accuracy of the actigraph methodology in assessing the sleep/wake profile of insomniacs.

The actigraph data analysis software: I. A novel approach to scoring and interpreting sleep-wake activity

Decades of empirical observations have established the validity of actigraphy primarily in individuals without sleep disorders. Methodological problems encountered thus far coupled with the widespread use of actigraphy signal the need for concentrated efforts to establish a consensus regarding scoring procedures. Currently available scoring methods show less reliability in clinical populations. To address these issues two validation studies were conducted: one for individuals without sleep disorders and the other for patients diagnosed with insomnia. The results of these two studies using the Actigraph Data Analysis Software as the scoring method have shown that the described system is fairly precise. It can be used for actigraphs with different features and mode of operation and is applicable to individuals with insomnia. These findings corroborate previous research showing that actigraphy is a valid instrument for assessment of sleep and wakefulness.

The actigraph data analysis software: II. A novel approach to scoring and interpreting sleep-wake activity

The widespread use of actigraphy has led to the recognition that a number of methodological issues have to be addressed to facilitate an increased acceptability of this relatively new method. These methodological issues include actigraph placement, reliability, and sensitivity, and the phenomenon known as the "first night effect." Our findings have demonstrated that actigraphy is a reliable instrument for assessment of sleep and wakefulness. In addition, actigraph placement and reliability do not constitute a significant methodological problem as no differences were found in all of these studies. We have also observed no first-night effects associated with sleep-wake monitoring with actigraphy.

Effects of diagnosis on treatment recommendations in chronic insomnia--a report from the APA/NIMH DSM-IV field trial

The objective of this study was to determine whether sleep specialists and nonspecialists recommend different treatments for different insomnia diagnoses according to two different diagnostic classifications. Two hundred sixteen patients with chronic insomnia at five sites were each interviewed by two clinicians: one sleep specialist and one nonsleep specialist. All interviewers indicated diagnoses using the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV); sleep specialists also indicated diagnoses according to the International Classification for Sleep Disorders (ICSD). Interviewers then indicated how strongly they would recommend each item in a standard list of treatment and diagnostic interventions for each patient. We examined differences in treatment recommendations among the six most common DSM-IV diagnoses assigned by sleep specialists at different sites (n = 192), among the six most common ICSD diagnoses assigned by sleep specialists at different sites (n = 153), and among the six most common DSM-IV diagnoses assigned by nonspecialists at different sites (n = 186). In each analysis, specific treatment and polysomnography recommendations differed significantly for different diagnoses, using either DSM-IV or ICSD criteria. Conversely, different diagnoses were associated with different rank orderings of specific treatment and diagnostic recommendations. Sleep specialist and nonspecialist interviewers each distinguished treatment recommendations among different diagnoses, but in general, nonspecialists more strongly recommended medications and relaxation treatments. Significant site-related differences in treatment recommendations also emerged. Differences in treatment recommendations support the distinction between different DSM-IV and ICSD diagnoses, although they do not provide formal validation. Site-related differences suggest a lack of consensus in how these disorders are conceptualized and treated.

Telepathology: a new tool of pathology? Presentation of a French national network

The field of pathology is constantly growing and the responsibility of the pathologists has progressively increased in the decision of application of some efficient but aggressive therapies. They justify the increasing necessity of discussion between pathologists about the diagnoses of difficult or rare or severe lesions. It is now possible to discuss at distance on good definition digitized images transmitted through I.S.D.N. A French experimental network between 12 workstations has been introduced since 2 years. Difficult or severe diagnoses have been immediately solved in 85% of the discussed cases. It remain legal problems and the necessity of an evaluation protocol which could be discussed at a European level. The increase of technical progress and, above all, the decrease of the costs might favour the development of telepathology. The workstation of the pathologist in the year 2000 could be the combination of a microscope, a HD-TV-camera and a personal computer with many softwares allowing treatment and transmission of numerous pictures.

Sleep evaluation in chronic insomniacs during 14-day use of flurazepam and midazolam

This article contains the sleep results of the efficacy study of flurazepam 30 mg and 15 mg, midazolam 15 mg, and placebo in the 99 chronic insomniacs studied as part of this multicenter study. After a 20-day drug washout, all-night sleep was recorded on 2 baseline nights, on the first 2 treatment nights, on treatment night 7, and on the last 2 nights of the study (nights 13 and 14). To reduce the number of comparisons, electroencephalographic (EEG) sleep latency, EEG wake time, EEG sleep efficiency, post-sleep questionnaire (PSQ) sleep latency, and PSQ total sleep were preselected as the major sleep variables. Between-groups comparisons indicated that, when compared with the placebo control, all drugs improved sleep, but differences were statistically significant only for the first 2 nights, i.e., the early interval. Midazolam was more effective than either dose level of flurazepam on treatment night 1. Within-group analyses indicated that all drug groups showed significantly improved sleep from baseline throughout drug administration, but the placebo group did not significantly improve from baseline by either objective or subjective measures at any of the three time intervals. The sleep of patients taking flurazepam 30 mg did not differ significantly from the sleep of those receiving the 15 mg dose for any of the five major sleep variables at any interval. Objective EEG and subjective PSQ sleep variables showed significant positive correlations.

Clinical safety of flurazepam and midazolam during 14-day use in chronic insomniacs

Data from evening questionnaires, reports of side effects, laboratory findings, and all-night respiratory measurements were collected on the 99 chronic insomniacs examined in this multicenter study. These data were used to compare the clinical safety and desirability of a benzodiazepine hypnotic with a very short half-life, midazolam 15 mg, with a hypnotic with a longer half-life, flurazepam 15 and 30 mg; both compounds were compared with a placebo control. There were 2 prestudy placebo nights followed by 14 consecutive nights of treatment. Of the 107 patients accepted, 99 completed the study. No marked adverse reactions were found in any area for any group. There was no increase in sleep apneas during the treatment period for any group. Results of this study provide additional evidence of the safety of benzodiazepine hypnotics.

[Extrapancreatic organ manifestations of pancreatic pseudocysts]

Hepatosplenomegaly is seldom caused by cystic tumefactions. 4 cases are presented, in which pseudocysts of the pancreas invaded and enlarged the spleen or liver.

Persistent psychophysiologic (learned) insomnia

Persistent psychophysiologic (learned) insomnia (PPI) is an objectively verifiable sleep disturbance that develops secondary to chronic, somatized tension and negative conditioning. Twenty-two patients diagnosed as PPI were compared on sleep and psychological questionnaires to 22 normal subjects (Ns) and to 19 insomnia patients with dysthymic disorders (DD). PPI patients typically had difficulties initiating and maintaining sleep, as did the DDs, but showed normal sleep staging. While PPIs were similar to Ns on most psychological tests, they typically were repressors and sensation avoiders. Many PPI patients suffered from tension-related symptoms such as headaches. PPI patients and Ns revealed less psychopathology than DD patients on almost all psychological scales.

The effects of midazolam and temazepam on sleep and performance when administered in the middle of the night

A multicenter, double-blind, sleep laboratory and performance study was conducted to evaluate the hypnotic efficacy and residual effects of midazolam (15 mg) and temazepam (30 mg) compared to placebo when administered in the middle of the night. Eighteen volunteers with objectively verified sleep maintenance insomnia received placebo for 3 nights during week 1 (adaptation and screening). During weeks 2, 3, and 4 they received 2 consecutive nights of midazolam, temazepam, and placebo (one treatment per week) in a balanced crossover design. Treatment was administered in the middle of the night (3.5 hours after bedtime). Neither drug reduced the latency to return to sleep after the middle of the night awakening. Both drugs significantly increased total sleep time, reduced wake during sleep, and number of awakenings over 4.5 hours in bed after treatment. In the morning (5 to 6.5 hours postdrug) significant performance decrements and reduced daytime sleep latency (7 hours postdrug) were found with temazepam but not midazolam.

What is the moment of sleep onset for insomniacs?

Subjective estimates of sleep latency were compared with three EEG-assessed measures of sleep onset: (a) the traditional one, i.e., the first epoch that is scored as stage 2 sleep; (b) the beginning of the first 15 min of uninterrupted stage 2 sleep; and (c) the beginning of the first 30 min of uninterrupted stage 2 sleep. A total of 56 insomniacs and 10 good sleepers were studied for 3 nights each in the laboratory. The traditional measure of sleep latency agreed best with the subjective estimates of good sleepers. Most insomniacs, however, were best able to estimate their sleep latency when the 15-min criterion was used. We suggest that for most insomniacs the subjective experience of being asleep occurs later in the EEG-defined transition from waking to sleeping than it does for good sleepers.

Sleep laboratory and performance evaluation of midazolam in insomniacs

This study evaluated laboratory sleep and performance after placebo, after 5, 10 and 20 mg of midazolam and after 30 mg of flurazepam. EEG recordings showed that 20 mg of midazolam significantly decreased sleep latency and stage 1 sleep, increased stage 2 sleep, and delayed the onset of the first REM period when compared with placebo. Subjective reports from the patients showed that the dose decreased the frequency of awakenings. In the morning, 9 h after drug ingestion, performance on most tests was affected very little by 20 mg of midazolam. However, performance on two psychomotor tests was slightly impaired after 20 mg of midazolam, while a test of free recall was slightly improved. On most variables, 5 mg of midazolam acted like placebo, while 10 mg of midazolam was intermediate between placebo and 20 mg of midazolam. Preliminary data suggest that 20 mg of midazolam may be as efficacious in inducing sleep as 30 mg of flurazepam, but may show fewer performance decrements in the morning.

Treating psychophysiologic insomnia with biofeedback

After evaluating 165 insomniacs, 48 psychophysiologic insomniacs were randomly assigned to one of the following four groups: electromyographic (EMG) feedback, combined EMG and theta feedback, sensorimotor rhythm (SMR) feedback, and no treatment (control). Sleep evaluations by home logs and in the laboratory were done before and after biofeedback and nine months later. No feedback group showed improved sleep significantly more than did the controls. The amount of feedback learning correlated significantly with sleep improvement for the SMR group but not for the other groups. Initial tension of the insomniacs correlated positively with sleep improvement for the EMG group, but negatively with sleep improvement for the SMR group. Those treated with the biofeedback that seemed appropriate for their specific deficiencies showed significant sleep improvements, while those who received inappropriate feedback did not. Appropriate biofeedback methods may be effective for specific types of insomnia, but these procedures offer no panacea for all poor sleep.

Childhood-onset insomnia

Twenty patients who had been insomniac since childhood were compared with 39 who had become insomniac during adult life. The childhood-onset insomniacs took longer to fall asleep, slept less, and showed excessive amounts of REM sleep without eye movements. Adult-onset insomniacs showed more restless sleep. No differences between childhood- and adult-onset groups were found on personality inventories, but those with childhood-onset insomnia reported more evidence of possible "soft" neurological impairment.

The wakeful "type A" student

Eight type A students and eight that were type B slept in the laboratory for three consecutive nights. Type A showed more fragmented sleep, i.e., more spontaneous awakenings from sleep. No differences in REM pressure between As and Bs could be demonstrated, contradicting the hypothesis that both the personality traits of type A individuals and their coronary-proneness might be explained by chronic REM deprivation of type A individuals.

Idiopathic hypoventilation syndrome: importance of preventing nocturnal hypoxemia and hypercapnia

This report describes a young woman with unexplained chronic hypoventilation that was greatly exacerbated during sleep. Treatment with nocturnal O2 during a 2-yr period was associated with stable cardiovascular function but severe morning headaches and lethargy, presumably related to nightly bouts of hypercapnia and acidosis during sleep. A subsequent 2-yr period in which ventilation was assisted during sleep by means of a rocking bed, but supplementary O2 was not used, was associated with disappearance of the headaches and improved psychosocial function, but with the insidious development of signs of pulmonary hypertension and right ventricular hypertrophy. This patient's clinical course demonstrates the separate adverse effects of intermittent hypoxemia and hypercapnia and emphasizes the importance of preventing both hypoxemia and hypercapnia during sleep.

Effectiveness of intermediate-term use of secobarbital

Secobarbital, 100 mg, was evaluated in two separate sleep laboratory drug evaluation studies, each with 4 insomniac patients. In both studies, the effect of secobarbital in inducing and maintaining sleep was evaluated, as well as the effects of the drug on sleep stages. Statistical analysis demonstrated that the results of the two studies could be combined. With short-term drug administration of secobarbital (up to 3 nights), there was an improvement in both sleep induction and sleep maintenance. Total wake time was decreased 43% below baseline and was consistently decreased in each third of the night. With intermediate-term drug administration (2 wk), total wake time was decreased only 14% (not statistically significant). Following drug withdrawal, the degree of sleep difficulty returned to baseline levels. The results indicate that secobarbital 100 mg is effective for short-term use but loses much of its effectiveness with intermediate use and suggest that the drug is of limited value for insomniac patients who require nightly medication beyond a period of 1 wk. With short-term administration, secobarbital induced a slight decrease in rapid eye movement (REM) and slow-wave sleep and a significant increase in stage 2 sleep. With intermediate administration, sleep stage values were similar to baseline levels. Following withdrawal, there was only a minimal increase in REM sleep above baseline levels, a significant increase in stage 3 sleep, and a significant decrease in stage 2 sleep. The rebound increase in stage 3 sleep is similar to that reported following withdrawal of pentobarbital.

Auditory awakening thresholds in REM and NREM sleep stages

The auditory awakening thresholds of the major electroencephalographically defined sleep stages were compared. A modification of the method of constant stimuli was used in an apparently successful attempt to minimize the incorporation of the experimental stimuli into the mental activity of the sleeper. A total of 319 experimental trials were distributed among seven human Ss who served for about six experimental nights each. The sequence and timing of experimental trials were counterbalanced to control for nights, habituation, amount of accumulated sleep, and amount of sleep since last awakening. The results showed approximately equal awakening thresholds during REM periods (the rapid eye movement stage of sleep) and stage 2 (low voltage EEG and 12 to 14 cps “sleep spindles”). Both these stages had lower awakening thresholds than delta sleep (large slow EEG waves). Awakening thresholds became lower with accumulated sleep, independent of sleep stage. There were no significant stage independent relationships between awakening threshold and time since last awakening or time since last body movement, although the latter were varied over a relatively narrow range which limits the generality of these findings. There was no stage independent relationship between heart rate and awakening threshold. The possible physiological determinants of the awakening response were discussed.