Safety and short-term outcomes of laparoscopic sleeve gastrectomy as a revisional approach for failed laparoscopic adjustable gastric banding in the treatment of morbid obesity

Laparoscopic sleeve gastrectomy (LSG) has been used as a first step of a two-stage approach in bariatric surgery for high-risk patients. Recently, LSG is being utilized as a primary and final procedure for morbid obesity with acceptable short-term results. The aim of this study is to investigate the effectiveness of LSG as a revisional procedure for patients with unsatisfactory outcomes after laparoscopic adjustable gastric band (LAGB). A retrospective review of a prospectively maintained database was performed. Data were reviewed for all patients undergoing revision from LAGB to LSG during the period May 2005 and May 2009. Data collected included demographics, indication for revision, operative time, length of stay, postoperative complications, and degree of weight reduction. Fifteen patients (three males and 12 females) had revisional surgery converting a LAGB to a LSG. The indication in four patients (26.66%) was weight regains and in five patients (33.33%) was poor weight loss; four patients (26.66%) had a band slippage and symptoms of gastroesophageal reflux, and one patient (6.66%) had poor weight loss, band slippage, and reflux. In one patient (6.66%), the indication was slippage and duodenal fistula. One-step revision procedure was done in 13 patients (86.66%), while two-step procedure was done in two patients (13.33%). Mean preoperative weight and BMI were 233.02 (181.4-300) lb and 38.66 (29.7-49.3) kg/m2, respectively. Mean weight loss at 2, 6, 12, 18, and 24 months postoperatively was 20.7, 48.3, 57.2, 60.1, and 13.5 lb, respectively. Mean % excess BMI loss was 28.9%, 64.2%, 65.3%, 65.7%, and 22.25% at 2, 6, 12, 18, and 24 months, respectively. There was one major complication (staple line leak) and one postoperative acute gastric outlet obstruction. We had no mortality. Thirteen patients were followed up postoperatively. The number decreased as follow-up time progressed. LSG could provide short-term weight loss after previously failed LABG, but prone to more complications compared to an initial LSG without a prior bariatric procedure.

Parcours multidisciplinaire du candidat à une gastroplastie

The decision to perform gastroplasty must be made by a multidisciplinary team. This organization ensures compliance with good practice guidelines. Multidisciplinary management after surgery is also essential but patients' adhesion to follow-up is relatively poor.

Novel virtual Lap-Band simulator could promote patient safety

This paper presents, for the first time, a physics-based modeling technique for the Lap-Band (Inamed Health) used in laparoscopic gastric banding (LAGB) operations for treating the morbidly obese. A virtual LAGB simulator can help train medical students as well as surgeons who embark at learning this relatively new operation. The Lap-Band has different thickness and curvature along the centerline, and therefore leads to different deformation behaviors. A hybrid modeling strategy is therefore adopted to successfully replicate its dynamics. A mass-spring model, used to model the less stiff part, is coupled to a quasi-static articulated link model for the more stiff and inextensible part. The virtual Lap-Band model has been implemented into a complete graphics-haptics-physics-based system with two PHANToM Omni devices (from Sensible Technologies) being used for real-time bimanual interaction with force feedback.

Endoscopic therapies of gastroesophageal reflux disease

The high prevalence of gastroesophageal reflux disease (GERD) in Western societies has accelerated the need for new modalities of treatment. Currently, medical and surgical therapies are widely accepted among patients and physicians. New potent antisecretory drugs and the development of minimally invasive surgery for the management of GERD are at present the pivotal and largely accepted approaches to treatment. The minimally invasive treatment revolution, however, has stimulated several new endoscopic techniques for GERD. Up to now, the data is limited and further studies are necessary to compare the advantages and disadvantages of the various endoscopic techniques to medical and laparoscopic management of GERD. New journal articles and abstracts are continuously being published. The Food and Drug Administration has approved 3 modalities, thus gastroenterologists and surgeons are beginning to apply these techniques. Further trials and device refinements will assist clinicians. This article will present an overview of the various techniques that are currently on study. This review will report the efficacy and durability of various endoscopic therapies for gastroesophageal reflux disease (GERD). The potential for widespread use of these techniques will also be discussed. Articles and abstracts published in English on this topic were retrieved from Pubmed. Due to limited number of studies and remarkable differences between various trials, strict criteria were not used for the pooled data presented, however, an effort was made to avoid bias by including only studies that used off-PPI scoring as baseline and intent to treat.

[Study of quality assurance "surgical treatment of morbid obesity" since 1.1.2005]

Since January 1st 2005, the situation of bariatric surgery has been examined in Germany. The data are registered in cooperation with the An-institute of quality control in surgery at the Otto-von-Guericke-Universität Magdeburg. The data registration occurs in an internet on-line data bank. Application for participation in this study is available on our correspondence address. All hospitals carrying out bariatric surgery are asked to take part in this study.

Quality Assurance in Bariatric Surgery

Quality assurance is a function that exists in manufacturing,engineering, and the service industry. Bariatric surgery is an undertaking with a special form of consumer product and service. In this day of limited resources and significant value exchanges among stakeholders (ie, patients, surgeons, third-party payers),the goal of the bariatric community is to deliver quality outcomes with safety, efficacy, and efficiency. The American Society for Bariatric Surgery and the Surgical Review Corporation, in conjunction with the bariatric community, will use quality assurance methods to produce quality outcomes that will satisfy the value exchanges of all stakeholders.

Efficacy of the SF-36 questionnaire in identifying obese patients with psychological discomfort

BACKGROUND

The primary endpoint of this study was to assess the association of health-related quality of life (QoL) and the presence of psychopathology. The association of other patients' characteristics and of Cognitive Behavioral Assessment (CBA) scales with quality of life (QoL) was also evaluated.

METHODS

100 consecutive obese patients (WHO grade 2 and 3 obesity), addressed for psychological advice before either invasive or non-invasive treatment of obesity, were investigated. The instruments used were the SF-36 questionnaire (physical and mental component summaries, PCS and MCS), the CBA scales and psychological counselling. The association of PCS and MCS with the presence of psychopathology (Marked or DSM IV discomfort) was assessed by means of logistic regression.

RESULTS

SF-36 PCS was 39.5 (95% CI 37.7-41.3) and MCS 49.8 (95% CI 47.7-51.9). PCS only was significantly lower than the average for the reference normal population. The mean PCS score was similar in the No-Moderate (39.6 (SD 7.6)) and Marked-DSM IV (39.1 (SD 7.6)) groups, with an adjusted odds ratios (OR) of 1.07 (95% CI 0.74-1.55), P=0.706, for 5 points increase in PCS. The mean MCS score was 51.7 (SD 10.3) in the No-Moderate group and 42 (SD 8.1) in the Marked-DSM IV group, with an adjusted OR for 5 points increase in score of 0.63 (95% CI 0.43-0.95), P=0.003.

CONCLUSIONS

SF-36, and particularly the MCS component, is a simple tool of easy use that could be utilized for identifying patients needing a specific psychological intervention in severely obese subjects applying for a weight reduction program.

[Clinical Practice Guidelines 2004. Standards, Options and Recommendations for the management of patient with adenocarcinoma of the stomach: radiotherapy (therapeutic evaluation)]

CONTEXT

The "Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the Federation of French Cancer Centers (FNCLCC), the 20 French regional cancer centers, and specialists from French Public Universities, General Hospitals and Private Clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and the outcome of cancer patients.

OBJECTIVES

To elaborate clinical practice guidelines for patients with stomach adenocarcinoma. These recommendations cover the diagnosis, treatment and follow-up of these tumors.

METHODS

The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery. The Standards, Options and Recommendations are thus based on the best available evidence and expert agreement.

RESULTS

This guidelines presents the synthesis of the data concerning the evaluation of the therapeutic ones. The main questions concern the type of gastrectomy to realize (Total Gastrectomy or gastrectomy subtotal), the extent of the lymphadenectomy (D2, D3 versus D1, D3, D2 versus D4) and the role of postoperative chemotherapy and adjuvant concomitant chemoradiotherapy.

Obesity surgery in a rural setting

BACKGROUND

The authors set out to determine the ability to perform and the success of bariatric surgery within a rural setting.

METHODS

Patients were selected in a retrospective manner between January 1999 and March 2002. Over this period, 112 consecutive patients underwent an open vertical banded gastroplasty (VBG) by a single surgeon. 60 of these patients were contacted by phone and were asked to answer a standardized questionnaire. Their medical histories were also examined.

RESULTS

100% of patients were seen by the dietician (in both group and individual settings) and the anesthetist preoperatively. VBG was successful in more than 85% of patients, and weight loss was maintained over the study period. There was no mortality. Three patients required endoscopic stitch excision, one patient had the VBG reversed, and two required a repeat VBG.

CONCLUSIONS

Obesity surgery can be achieved in a rural setting with minimal morbidity and successful weight loss.

Obesity surgery: evidence-based guidelines of the European Association for Endoscopic Surgery (EAES)

BACKGROUND

The increasing prevalence of morbid obesity together with the development of laparoscopic approaches has led to a steep rise in the number of bariatric operations. These guidelines intend to define the comparative effectiveness and surrounding circumstances of the various types of obesity surgery.

METHODS

A consensus panel representing the fields of general/endoscopic surgery, nutrition and epidemiology convened to agree on specific questions in obesity surgery. Databases were systematically searched for clinical trial results in order to produce evidence-based recommendations. Following two days of discussion by the experts and a plenary discussion, the final statements were issued.

RECOMMENDATIONS

After the patient's multidisciplinary evaluation, obesity surgery should be considered in adults with a documented BMI greater than or equal to 35 and related comorbidity, or a BMI of at least 40. In addition to standard laboratory testing, chest radiography, electrocardiography, spirometry, and abdominal ultrasonography, the preoperative evaluation of obesity surgery patients also includes upper gastrointestinal endoscopy or radiologic evaluation with a barium meal. Psychiatric consultation and polysomnography can safely be restricted to patients with clinical symptoms on preoperative screening. Adjustable gastric banding (GB), vertical banded gastroplasty (VBG), Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) are all effective in the treatment of morbid obesity, but differ in degree of weight loss and range of complications. The choice of procedure therefore should be tailored to the individual situation. There is evidence that a laparoscopic approach is advantageous for LAGB, VBG, and GB (and probably also for BPD). Antibiotic and antithromboembolic prophylaxis should be used routinely. Patients should be seen 3 to 8 times during the first postoperative year, 1 to 4 times during the second year and once or twice a year thereafter. Outcome assessment after surgery should include weight loss and maintainance, nutritional status, comorbidities and quality-of-life.

Bariatric and Associated Operations in Private and Academic Practices

BACKGROUND

The types of bariatric and the associated operations performed by academic and private surgeons were surveyed.

METHODS

A survey containing 8 questions regarding type of practice, type of surgery, associated procedures during bariatric surgery, years in practice and bariatric training was e-mailed to all members of the American Society for Bariatric Surgery.

RESULTS

46% of the members responded and were divided between those who performed their procedures laparoscopically and those who performed open procedures. Laparoscopic adjustable gastric banding was almost exclusively performed in academic centers and encompassed 20% of their bariatric operations, while the gastric bypass was the most common operation performed (65%), followed by vertical banded gastroplasty and duodenal switch. Operations performed simultaneously indicated that cholecystectomies were performed equally in private practice (92.5%) and the academic sector (95%), with higher incidence in open procedures (95%) compared to laparoscopic (40%). Of the surgeons performing appendectomies, 20% were in private practice and 10% in academic. Liver biopsy was performed with the same incidence in private and academic practices (60%). A minority of responders had formal fellowship training (17%), and many had learned from a partner (40%). The approach was dictated by the surgical training (85%) and background.

CONCLUSION

No significant difference was found between the private and academic surgeons in performing operations. Appendectomy is rarely performed academically, and cholecystectomy is mostly performed in the open procedure.

Bariatric surgery for severely overweight adolescents: concerns and recommendations

As the prevalence of obesity and obesity-related disease among adolescents in the United States continues to increase, physicians are increasingly faced with the dilemma of determining the best treatment strategies for affected patients. This report offers an approach for the evaluation of adolescent patients' candidacy for bariatric surgery. In addition to anthropometric measurements and comorbidity assessments, a number of unique factors must be critically assessed among overweight youths. In an effort to reduce the risk of adverse medical and psychosocial outcomes and increase compliance and follow-up monitoring after bariatric surgery, principles of adolescent growth and development, the decisional capacity of the patient, family structure, and barriers to adherence must be considered. Consideration for bariatric surgery is generally warranted only when adolescents have experienced failure of 6 months of organized weight loss attempts and have met certain anthropometric, medical, and psychologic criteria. Adolescent candidates for bariatric surgery should be very severely obese (defined by the World Health Organization as a body mass index of > or =40), have attained a majority of skeletal maturity (generally > or =13 years of age for girls and > or =15 years of age for boys), and have comorbidities related to obesity that might be remedied with durable weight loss. Potential candidates for bariatric surgery should be referred to centers with multidisciplinary weight management teams that have expertise in meeting the unique needs of overweight adolescents. Surgery should be performed in institutions that are equipped to meet the tertiary care needs of severely obese patients and to collect long-term data on the clinical outcomes of these patients.

Reduced length of stay by implementation of a clinical pathway for bariatric surgery in an academic health care center

Bariatric surgery is being performed in increasing numbers in an era when reimbursements are being reduced. Academic health centers bear the responsibility for training surgeons to perform these operations yet must keep costs to a minimum and retain high quality. The UCLA Bariatric Surgery Program developed a clinical pathway for the pre- and postoperative management for gastric bypass patients to achieve these goals. Medical records for 182 consecutive gastric bypass patients were retrospectively reviewed before implementation of the pathway (Group I) during the fiscal year of 1998/1999. Data on average length of stay, average intensive care unit length of stay, average standard variable cost, percentage readmission rate, and percentage return to the operating room were collected. This information was compared with the data collected prospectively from 182 patients after implementation of the pathway in July of 1999 (Group II) during the fiscal year of 1999/2000. Hospital cost per admission was reduced by 40 per cent in Group II compared with Group I (P < 0.02). The average length of stay was reduced from 4.05 days in Group I to 3.17 days in Group II (P < 0.033). Overall readmission rate was decreased from 4.2 per cent in Group I to 3.2 per cent in Group II (P < 0.05). There were no differences in morbidities between both groups. The pathway reduced costs by reducing the hospital length of stay, intensive care unit utilization, and readmission rates. Quality was maintained as evidenced by a similar pattern of postoperative morbidities yet readmission rates were reduced. Our results indicate that implementation of a clinical pathway for bariatric surgery reduces cost and improves quality of care in an academic institution.

Eating pattern in the first year following adjustable silicone gastric banding (ASGB) for morbid obesity

OBJECTIVE

To analyse the relationships between eating pattern, vomiting frequency, weight loss and the rate of band related complications in morbidly obese patients undergoing Adjustable Silicone Gastric Banding (ASGB).

SUBJECTS

80 morbidly obese patients (57 females and 23 males) consecutively operated by ASGB were evaluated both before and 3, 6 and 12 months after ASGB. Ten patients (12.5%) had binge eating disorder and were analysed separately.

MEASUREMENTS

(1) weight loss expressed as percentage of overweight, (2) total daily energy intake, (3) percentage of energy as lipids, carbohydrates and proteins, (4) percent as liquid, soft or solid foods and (5) vomiting frequency.

RESULTS

ASGB induced a highly significant reduction of total daily energy intake and percent as solid foods, without significant changes in macronutrient distribution. There was an inverse relationship between vomiting frequency and the intake of solid foods. Non-binge eaters with more vomiting ate less solid food and lost more weight than patients without vomiting. The frequency of neostoma stenosis was higher in patients with high vomiting frequency than in patients with no vomiting. Patients with binge eating disorder had a significantly higher vomiting frequency and a five-fold higher frequency of neostoma stenosis than patients without binge eating disorder. However, the percentage of overweight lost did not differ between patients with and without binge eating.

CONCLUSIONS

Vomiting is a major determinant of global outcome after ASGB. The vomiting frequency in the first months after ASGB was associated with eating pattern, the frequency of neostoma stenosis and possibly the rate of weight loss during the first year of follow-up.

A critical review of a personal series of 1000 gastroplasties

INTRODUCTION

In a world suffering from famine, it is paradoxical to find in Belgium and in most Western countries a marked tendency to obesity. A recent study has revealed that one Belgian out of five is overweight. The literature has provided evidence that behaviour modification or dietary therapy do not result in long term weight loss for severe obese. As a result, more and more obese people are treated by surgery and we present here our personal experience of bariatric surgery during the last eight years. All the surgical procedures have been performed by a single surgeon as part of a multidisciplinary approach that also involves internists, dieticians, psychiatrists and basic scientists.

Gastroplasty for morbid obesity: the internist's view

To evaluate the benefit of gastric surgery in terms of improvement in health risk factors, the loss of weight and its long-term maintenance, 28 non-diabetic morbidly obese subjects were followed during three to five years after vertical banded gastroplasty. Aside from a rapid and sustained loss of weight averaging nearly 75% reduction of weight excess, there occurred a concomitant improvement in glucose tolerance with 50% reduction in fasting insulinaemia and correction of hypertension. The improvement in cardiovascular risk factors also included the drop in plasma triglycerides associated with an increase in HDL-cholesterol, while uricaemia decreased to low normal levels. Gastric procedures are therefore an effective treatment of severe obesity and of its comorbid conditions, but they should be followed by careful medical and nutritional monitoring to prevent any possible digestive or nutritional complications.

Vertical banded gastroplasty: is obesity worth it?

Obesity is a public health issue of major concern for the United States and other developed nations. In the last several decades, bariatric surgery has developed as a means of treating morbid obesity. Vertical banded gastroplasty (VBG) is an attractive procedure because it has fewer side effects than other forms of bariatric surgery and maintains physiological continuity of the gut. VBG was performed in 36 patients at a rural community hospital from 1982-1990. There was only one intraoperative complication necessitating splenectomy and two early postoperative complications--gastric leak and marginal stress ulcer--necessitating reexploration. Twenty-five patients were available for follow-up, at which time they were an average of 6.4 years out of surgery. Two of these patients had died, both from cardiac arrest months or years after VBG. The remainder had gone from a preoperative average of 86.7% over ideal weight according to 1983 Metropolitan Life insurance Tables to 54.5% over ideal weight. Mean BMI for this group had changed from 41.2 preoperatively to 34.7 at follow-up. Success was defined as weight loss to < 60% over ideal or BMI < 35, removing the individual from the morbidly obese category. According to this criteria, VBG provided successful weight loss in 72% of subjects in the follow-up group. Weight loss results may have been biased as a significant number of patients were lost to follow-up and may have constituted failures. In general, most individuals did not make concomitant changes in diet or sedentary life-style which would have supported weight loss effected by VBG. Moreover, regain of weight was progressive and possibly inexorable. Nearly all individuals nonetheless reported great satisfaction with their surgery. VBG is a viable option in the treatment of morbid obesity, but criteria for success needs to be better defined in order to determine whether the procedure is "worth it."

Gastrointestinal surgery for severe obesity: National Institutes of Health Consensus Development Conference Statement

The National Institutes of Health Consensus Development Conference on Gastrointestinal Surgery for Severe Obesity brought together surgeons, gastroenterologists, endocrinologists, psychiatrists, nutritionists, and other health care professionals as well as the public to address: the nonsurgical treatment options for severe obesity, the surgical treatments for severe obesity and the criteria for selection, the efficacy and risks of surgical treatments for severe obesity, and the need for future research on and epidemiological evaluation of these therapies. Following 2 days of presentations by experts and discussion by the audience, a consensus panel weighed the evidence and prepared their consensus statement. Among their findings, the panel recommended that (1) patients seeking therapy for severe obesity for the first time should be considered for treatment in a non-surgical program with integrated components of a dietary regimen, appropriate exercise, and behavioral modification and support, (2) gastric restrictive or bypass procedures could be considered for well-informed and motivated patients with acceptable operative risks, (3) patients who are candidates for surgical procedures should be selected carefully after evaluation by a multidisciplinary team with medical, surgical, psychiatric, and nutritional expertise, (4) the operation be performed by a surgeon substantially experienced with the appropriate procedures and working in a clinical setting with adequate support for all aspects of management and assessment, and (5) lifelong medical surveillance after surgical therapy is a necessity. The full text of the consensus panel's statement follows.