6th World Congress of theInternational Federation for the
Surgery of Obesity (IFSO)3rd International Symposium on
Laparoscopic Obesity Surgery (ISLOS)15th International Symposium on Obesity Surgery
September 5-8th, 2001, Chania, Crete, Greece
MESSAGE FROM THE PRESIDENT OF THE 6th WORLD CONGRESS
Crete was the cradle of the Minoan Civilization (2700-1100 BC), considered to be the most advanced ancientcivilization in Europe. Religious, Magic and Empirical Medicine as well as Elementary Surgery and Dentistrywere practiced during the Minoan period. Cretan therapists were using herbs as pharmaceutical agents to alle-viate war injuries and facilitate deliveries. In Crete one can find two of the most famous “Asclepeion" of AncientGreece—that of Lebena in the South of the island and that of Lissos the west part of Crete. Patients from allover Crete, but also from Southern Greece and North Africa, were traveling to those Ancient Clinics to seekmedical attention.
Dear Friends, I have the pleasure and the honor to invite you to the 6th World Congress of IFSO on the island of Crete withits remarkable history of Medicine.
The Congress will take place in the city of Chania, the second biggest but most beautiful town in Crete. Theweather during September is ideal to combine scientific engagement with holidays and enjoy the beach, the nat-ural beauties and the archaeological sights of the island.
During the Congress we will discuss all major issues related to antiobesity surgery. Leading experts from allover the world will be there to present their valuable experience. Two major conference rooms will be available forthe oral presentation and the video sessions, and there will be a poster and medical exhibition.
The Congress will take place in the Orthodox Academy of Crete, in Kolimbari, a village situated about 22 kmfrom Chania, in the foot of a mountain and near the sea, where no one can disturb the stillness and quietnessof the place.
The welcome reception will take place in the port of the old town with the fantastic view of the Venetian light-house. A farewell Cretan night is also scheduled. I hope that everyone will have the opportunity to meetold friends here and make new ones. I look forward to welcoming you in Crete.
John MelissasPresident of the Congress
P R O G R A M
IFSOPresident: Andrew C. Jamieson
Executive Director: Mervyn DeitelPast President: Emanuel HellPresident Elect: Martin Fried
Vice President: Aniceto BaltasarSecretary Treasurer: Arthur B. Garrido, Jr.
Honorary President: Nicola ScopinaroBoard of Trustees: George S.M. Cowan, Jr.
Organized by the Greek Societyfor Bariatric Surgery
Organizing Secretariat:Mrs. Christina Kotsaki,
University General Hospital,P.O. Box 1352,
Heraklion 71110,Crete, Greece
Tel: +30-81-392387; Fax: +30-81-542090
346 Obesity Surgery, 11, 2001
GENERAL INFORMATIONVenueOrthodox Academy of Crete, Chania Crete, Greece, September 5-8, 2001.A bus shuttle service will provide connection with the congress hotels.
Official Language: English
CurrencyGreek Drachmas (GRD)Exchange rates:1 U.S.$ ± 400 Grd (indicative; check with your bank for current rate),1 Euro ± 340 Grd.
Credit Cards—ExchangeCredit Cards are widely accepted at department stores, shops, restaurants and nightclubs. Currency can beexchanged at your hotel, travel agent or other tourist offices operating in the city, as well as banks.
InsuranceThe Organizers cannot accept responsibility for accidents which might occur. Delegates are encouraged to obtaintravel insurance (medical, personal accident, and luggage), in their home country.
Electrical AppliancesGreece operates on 220 volts for electrical appliances. The frequency is 50Hz.
Bank—ShopsThe business hour of most department stores are from 08.30 to 20.30. They are open on weekdays and Saturdays butclosed on Sundays and National holidays. Banks are open from 08.00-2.00 on Mondays, Tuesdays, Wednesdays andThursdays from 08.00 to 01.30 on Fridays.
TransportationBuses are available for nearly all destinations from Chania. If you need a taxi from Congress Hotels, please call 98700and 87700 (use 0821 when calling from a mobile phone, followed by the telephone number). From the Conference Hallcall a taxi at (0824) 23322.22230.22140 or 22333.Useful telephones: Chania General Hospital: (0821) 22000, Police 100, Airport: (0821) 63224.
Weather and ClothingThe weather in Crete is ideal during September. It is neither too hot nor windy and autumn is still far to come. Rain isextremely unusual for this time of the year in Chania. Sea water is ideal for swimming. Day temperature ranges from24o to 32oC (75o - 89o F). Nevertheless, you could bring a sweater with you in case of chilly nights.
How to get to ChaniaYou can reach Chania by two different means of transportation:) by plane (preferably) and by boat. There are flightsevery day from Athens by Olympic Airways, Aegean Airlines and Cronus Airlines. The trip lasts approximately 40 min.Taxi fare from the airport to the Congress Hotels and/or to the Conference Hall is about Grd 8.000-10.000, dependingon the distance. However, a welcome desk will be set at Chania Airport by the organizers, during the Meeting, andtransportation from the Airport to the Hotel of your choice and to the Conference Hall and vice versa can be pre-arranged for those interested in this service.
Website: http://www.obesity-online.com/ifso 2001
SOCIAL PROGRAMWednesday September 5: Welcome Reception at Chania in the port of the Old Town,after the opening ceremony(cocktail and buffet dinner)Bus transfer from the Congress Hotels.Friday September 7 evening: Gala dinner, Cretan night with traditional Greek cuisine. Bus transfer from the CongressHotels.
BRING THIS PROGRAM ISSUE WITH YOUTO CRETE
The IFSO program portion with the abstracts in this issueis sponsored by BioEnterics Corporation
Obesity Surgery, 11, 2001 347
IMPORTANT DATES
September 5 0900-1200 hrs — Allied Health Session1300-1730 hrs — 3rd ISLOS2000 hrs — Welcome Reception and Buffet in the port of the Old Town of Chania
September 6-8 6th World Congress of IFSO, 15th International Symposium on Obesity SurgerySeptember 7 2030 hrs. — Gala Dinner, “Metoxi” Restaurant, Cretan night and cuisine
CONGRESS OPTIONAL TOURS
1. City Tour of Chania:Visit to the town’s most beautiful spots and sights. The Cathedral, the historic Monastery of St. Triada, the Hamam,the Arsenal, the Public Market and the Synagogue are only few of the sites you will be seeing.Price: 11.000 GRD Wed., Sept. 5; 0800-1400 hrs.
2. Samaria Gorge (lazy way):Enjoy the unique scenery of the longest gorge in Europe, and a swim in the crystal waters of the Libyan Sea. Visit to“Sfakia” village where the gorge comes to an end. Then an easy walk of about one hour will allow you to see a bigpart of the Gorge.Price: 15.000 GRD (entrance fees and boat are included). Thurs., Sept. 6 (lazy way); 0700-1600 hrs.
3. Knossos—Archaeological Museum of Heraklion:Experience power and the vitality of the era of the worldwide known Minoan civilization and witness the complexityof the Minoans’ lifestyle. Visit one of the most important museums in the world where original pieces from theNeolithic, Minoan and Greco-Roman periods are exposed.Price: 18.500 GRD (entrance fees to Knossos and the museum are included). Fri., Sept. 7; 0700-1600 hrs.
POST-CONGRESS TOURS*
1. Samaria Gorge:Experience the stunning drive through the White Mountains to the Plateau of Omalos, the unspoilt scenery, rareflora and the caves on the rugged mountain sides as well as the rare goat “Kri-Kri”.Price: 14.500 GRD
2. Santorini:Magical trip to an island of exceptional geological structure, which is the result of the eruptions of an now inactivevolcano. You will visit ancient “Thira”, you willl see the most beautiful sunset in “Oia”, you will swim in the crystalwaters of the warm sea and sunbathe on the red and black beaches with shingle.Price: 32.000 GRD (includes: transfers, boat fares, one night stay in **Hotel, excurison with guide).
3. Cretan Villages Tour:During this you will visit the Red Village where you will have the chance to see the procedure of making PhysicGlass. The next stop will be “Argyroupoli” town where you will see the natural waterfalls, and after that the beautifullae of “Kournas” and the village of “Vrisses” known for its honey and cheese products. Lastly, you will experience theoriginal procedure of winemaking in a local winery.Price: 12.500 GRD
4. Elafonissi:A tour of one of the most beautiful places in Crete, an island on the southwestern part of Crete. The coralline sandand the magnificent scenery offer the visitor a very special experience. On the way to Elafonissi you will stop at Elosvillage, a place full of chestnut trees, and at the Chrissoskalitissa Monastery. On the way back to Chania you willvisit the church of St. Sofia which is built in a cave with stalactites and stalagmites.Price: 10.600 GRD.
* Post-Congress Tours will be arranged during the Meeting. Please contact the Congress Secretariat for inquiriesand to make all the necessary arrangements.
348 Obesity Surgery, 11, 2001
CONGRESSThe congress will consist of plenary sessions and a permanent poster exhibit. An Award for the best Poster willbe given. Presentations will be oral and/or video. The Authors will be given a presentation time, and they will be freeof sharing between the oral and video part, without in any case exceeding the total time assigned. The 3rdISLOS will deal with novelties in laparoscopic obesity surgery and technical aspects.
Slide Presentation:Standard 35 mm slide projection (single or double).
Computer Presentation:Preferably with own PC laptop, otherwise use MS PowerPoint for Windows 98/00.
Video Presentation:VHS and all other programs available (Pal, Secam, NTSC).
Poster Instructions:Poster must be prepared to fit a board of 135 cm height and 90 cm width.
CONGRESS REGISTRATION FORM
Check Before April 30, 2001 After April 30, 2001IFSO Member* Grd 150.000 170.000Non-IFSO Member* 170.000 190.000Allied Care Professional** 60.000 65.0003rd ISLOS alone*** 30.000 35.000Accompanying Person**** 60.000 65.000Extra ticket for Gala Dinner 25.000 30.000T ourA - Knossos and Archeological Museum 18.500Tour B - Samaria Gorge 15.000Tour C - Chania City Tour 11.000
Total Amount Due*IFSO Membership entails subscription to the Journal OBESITY SURGERY.
*Includes 3rd ISLOS, coffee breaks, lunches, Welcome Reception and Gala Dinner.**Special reduced fee, includes 3rd ISLOS, coffee breaks, lunches, Welcome Reception.*** Includes Welcome Reception.****Includes Welcome Reception and Gala Dinner.
Cancellation until August 15: secretariat charge Grd 15.000; thereafter, no refund.Name______________________________________________________________________ _______________Address________________________________________________________________________________ ___City________________________ Postal Code__________________ Country__________________________Tel_________________________ Fax_________________________ E-mail___________________________
[] Credit Card Visa__________ Eurocard/Mastercard___________ American Express_________________Card no.________________________________________________ Expiry date_______________________Name of the card holder____________________________________________________________________Signature______________________________________________________________________ __________
[] Bank transfer to: Mrs. Christina Kotsaki, Agricultural Bank of Greece, Bank Account No. 366 01 103 698 71, Swiftcode 1110 (copy enclosed).
Send to: Mrs Christina Kotsaki University General Hospital
Aegean Palace Single 39.000Double 44.000Suite, private swimming pool 65.000
Santa Marina Single mountain view 24.000Double sea view 34.000Double mountain view 28.000
Chrispy Single 23.000Double 27.000Double/single occupancy 25.000
*GRD= Greek Drachmas, 1US $= ± 400 GRD, 1 EURO= ± 340 GRD (indicative rate)Prices include all rates and taxes. Child 0-2 years old free. 3rd person in double room 30% addition. A written confir-mation will be sent upon receipt of the reservation form. September in Chania is a very busy tourist period. A consis-tent number of rooms have been booked at the hotels listed above for the Congress. Nevertheless since the number ofparticipants is unforeseeable, early hotel reservation is strongly recommended (before May 31st, 2001). In case thehotel of choice is fully sold out, an alternative will be offered and reservation will be made only after approval. Dueto the limited number of the single rooms, they will be assigned on a first come, first served basis. Reservation requestsmust be accompanied with a two nights room deposit by bank transfer or credit card. Cancellation policy: to May 31sttotal refund, between June 1st and July 31st one night refund, after August 1st no refund.
Moderators: Nancy Mead, Greece; Mary-Lou Walen, U. S. A.
09:00 1. Obesity Surgery: Utility of psychological area in multidisciplinary team and future
challenges.
Susana Bayardo, RN. Instituto Multidisciplinario Especializado en el tratamiento y cirugia de la
Obesidad, Argentina.
09:12 2. Continuing Education, Our Responsibility to Teach Lessons of the Body, Bones and
Brains.
Jacquelyn K. Smiertka, RN. Bloomfield Bariatrics-Private Practice, Michigan, U.S.A.
09:24 3. The “INFO G” group: a Support Team for the Obese Patient.
Christian A.G. Thyse, RN. Centre Hospitalier Régional de Huy, Huy, Belgium.
09:36 4. Preliminary survey of sexual orientation after weight loss surgery in homosexual
females.
Delphine Nuglozeh-Buck, RN, Barbara Metcalf, RN, William Harman, Ph.D, Gregg H. Jossart, MD,
Robert A. Rabkin, MD. Pacific Laparoscopy, San Francisco, CA, U.S.A.
09:48 5. Pregnancy after Gastric Bypass.
Bobbie Lou Tripp, RN, Melvin S. Swanson, PhD, Paul Cunningham, MD, Walter Pories, MD, Sharon Ripley, RN, Bret Brown, RHIA, Kenneth MacDonald, MD. Brody School of Medicine, East
Carolina University, Greenville, NC, U.S.A.
Session 2
Moderators: Tracy Owens, U. S. A.; Christian A. G. Thyse, Belgium
10:00 6. Pre and Postoperative Protocol for Bariatric Surgical Patients.
Aggeliki Loukidi, Nancy Mead, Fotis Kalfarentzos, MD. Nutrition Support and Morbid Obesity Clinic,
Surgical Department, University Hospital of Patras, Greece.
10:12 7. Dietary Management of Patients with Morbid Obesity after Vertical Banded Gastroplasty.
Vassiliki Komessidou, A. Papakonstantinou, P. Alfaras, I. Terzis, P. Moustafellos, S. Gourgiotis,
S. Brousta, E. Hatjiyannakis. Depar tment of Nutrition and 1st Depar tment of Surgery,
“Evangelismos” General Hospital, Athens, Greece.
10:24 8. Coping Style and Eating Pattern in Obese and Morbidly Obese Patients who were Screened
Preoperatively for a Gastric Restriction Procedure.
Rogier Horchner, MSc, RN, Wim Tuinebreijer, MD, PhD, MSc. Department of Clinical Research
Ra-Medic & Dutch Obesity Clinic, Hilversum, The Netherlands.
10:36 9. Anesthetic Care in Morbid Obesity.
Adrian Alvarez, Antonio Jose Cascardo, Silvio Albarracin. IMETCO (Multidisciplinary Institute
Wednesday, September 5, 2001
ALLIED HEALTH SESSIONIPPOCRATES HALL
352 Obesity Surgery, 11, 2001
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Specialized in the Treatment and the Surgery of Obesity), Buenos Aires, Argentina.10:48 10. Bariatric Operation in a Patient with Possible Psychiatric Contraindication - Case Report.
A. P. Azevedo, H.T. Libanori, A. Segal. Institute of Psychiatry, Hospital das Clinicas, Sao Paolo
University Medical School, Sao Paolo, Brazil.
Session 3
Moderators: Elisabeth-Ardelt Gattinger, Austria; Kathy Fox, U. S. A.
11:00 11. Addictions? Role after Bariatric Surgery.
Elisabeth Ardelt-Gattinger, Irene Hofmann, Edda Angermann, Melodie Moorehead. Psychological Institute of University of Salzburg Austria; Holy Cross Hospital, Ft. Lauderdale, FL, U. S. A. .
11:12 12. A 15-year Evaluation of BPD Results According to BAROS Criteria.
Giuseppe M. Marinari, Giovanni Camerini, Federica Murelli, Francesco Papadia, Paola Marini, Cesare Stabilini, Flavia Carlini, Nicola Scopinaro. DICMI, Semeiotica Chirurgica R, University of Genoa School of Medicine, Genoa, Italy.
11:24 13. Preoperative Behavioral-Cognitive Psychotherapy for Bariatric Surgery Patients.
A. Mingardi, G. Crozeta, M.A. Larino, H.T. Libanori, A. Segal. Institute of Psychiatry, Hospital das Clinicas, Sao Paolo University, Medical School, Sao Paolo, Brazil.
11:36 14. Psychological factors and patient motives in relation to BMI reduction in morbidly obese patients following bariatric surgery.
Ioannis Vlachos O.**, Theofilos Stergiou**, Nancy Mead*, Stavroula Berati**, Fotis Kalfarentzos*. Nutrition Support and Morbid Obesity Clinic, Surgical Department* and Psychiatric
Department**, University Hospital of Patras, Greece.11:48 15. The Effects of Gastric Bypass Surgery on Measures of Psychological Distress.
Mary Gallacher, M.B., Ch.B., Cynthia Buffington, Ph.D., George S.M. Cowan, Jr., M.D. The University of Tennessee Health Science Center, Depar tment of Surgery and The Clinical Research Center, Memphis, Tennessee, U.S.A.
12:00 LUNCH (Allied Health Science Group Luncheon Meeting).
Session 1
Gastric Banding: Surgical Techniques.
Moderators: Carlos A. Casalnuovo, Argentina; Eliezer Avinoah, Israel
13:00 16. Lap-Band, Changes in Surgical Technique: Outcome of 1410 Surgeries Performed from July 1995 through April 2001.
Jean-Marie Zimmermann, Michel Blanc, Pierre Mashoyan, Érick Zimmermann, Jean-Marc
Wednesday, September 5, 2001
3rd International Symposium on LaparoscopicObesity Surgery (ISLOS)
IPPOCRATES HALL
Obesity Surgery, 11, 2001 353
Crete Program
Grimaldi. Clairval Private Hospital Center, Marseille, France.
13:12 17. Proximal Gastric Banding after Failed Gastric Restrictive Operations.
Eliezer Avinoah, Solly Mizrahi, Leonid Landsberg. Surgery A, Soroka Medical Center, Faculty of
Health Sciences, Ben-Gurion University, Beer-Sheva, Israel.13:24 18. Technical Modification in Lap-Band Implant.
Carlos Alberto Casalnuovo, Ezequiel Ochoa de Eguileor, Gustavo Parrilla, Marco More.
Hospital de Clínicas, University of Buenos Aires, and Private Practice (CCO-Centro de Cirugía de la Obesidad), Buenos Aires, Argentina.
13:36 19. LAP-BAND Gastric Banding in a Public University Hospital: Success and Pitfalls with 450 Patients in Four years.
Jean-Marc Chevalier, Franck Zinzindohoue, Jean-Philippe Blanche, Richard Douard, Jean Louis Berta, Jean Jacques Altman, Paul-Henri Cugnenc. Departments of Surgery and Nutrition. Hôpital
Europpéen Georges Pompidou, Paris, France.
13:48 20. Laparoscopic Gastric Banding: Why Changing To Another Technique?Ahmed Zayed, Mohammad Al-Jarallah. Armed Forces Hospital Kuwait, State of Kuwait.
Session 2
Special Lectures
Moderators: Ingmar Näslund, Sweden; Pierre Urbain, Belgium
14:00-14:30 Initial Results and Possible Mechanisms of Gastric PacingRobert Greenstein, U. S. A.
14:30-15:00 A Standardized Reproducible Approach for Laparoscopic Vertical Banded GastroplastyJean-Luis Allé, Belgium.
15:30 21. Modified Laparoscopic VBG for Treatment of Morbidly Obese Patients.John Melissas, George Schoretsanitis, John Grammatikakis, Demetrios Michaloudis, Demetrios
D. Tsiftsis. Bariatric Unit, Dept. Surgical Oncology, University Hospital, Heraklion, Crete, Greece.15:42 22. Laparoscopic Vertical Banded Gastroplasty (VBG) – Long-Term Outcome in 139 Patients.
Torsten Olbers, Hans Lönroth, Jan Dalenbäck*, Eva Haglind, Lars Lundell. Department of
Upper G.I Surgery, Sahlgrenska University Hospital and *Frolunda Specialist Hospital, Gothenburg, Sweden.
15:54 23. Laparoscopic Vertical Banded Gastroplasty: Results in 250 Cases with 5-years Follow–Up.
Mauro Toppino, Mario Morino, Danilo Donati, Luca Mazza, Valeria Costamagna. Department of
Surgery, University of Turin, Italy.16:06 24. Laparoscopic Vertical Banded Gastroplasty with Adjustable Band in the Treatment of Morbid
Obesity.
Giovanni Natalini, Francesco Guiggi, Luca Calzoni. Department of Surgery, Marsciano-Todi Hospital,
354 Obesity Surgery, 11, 2001
Crete Program
Marsciano, Italy.
16:18 25. Laparoscopic Long Vertical Gastric Stapling ± Sleeve Gastrectomy for the Treatment of Morbid
Obesity.
Simon P.L. Dexter, Michael J. McMahon, Nikos Georgopoulos. Leeds Institute for Minimally Invasive
Therapy, The General Infirmary, Leeds, UK.
Session 4
Laparoscopic Gastric Bypass
Moderators: Luigi Angrisani, Italy; Arthur B. Garrido Jr, Brazil
16:30 26. The Gagner Technique for Laparoscopic Gastric Bypass: Technical Observations and Details.
(Video)
Luigi Angrisani, Michele Maresca, Vincenzo Borrelli, Gaetano Cimmino, Monica Ciannella. Unit of Endoscopic Surgery, “S. Giovanni Bosco” Hospital, Naples, Italy.
16:42 27. Laparoscopic Roux-en Y Gastric Bypass with Silastic Ring (Capella’s procedure) in the
Treatment of Morbid Obesity: Technical Description in Video.
Thomas Szegö, Arthur B. Garrido Jr, Mitsunori Matsuda, Carlos José Lazzarini Mendes, Marcelo Roque de Oliveira, Alexander Elias, Luiz Vicente Berti. Private Practice, Albert Einstein and
Beneficência Portuguesa Hospital, São Paolo, Brazil.
A. Restuccia, D. Polito, G. Silecchia, A. Genco, U. Elmore, N. Perrotta, F. Greco, P. Fabiano, N. Basso.
Dipartimento di Chirurgia “Paride Stefanini”, Policlinico “Umberto l’ Università ”La Sapienza”, Roma, Italy.
17:06 29. Laparoscopic Roux-en-Y Gastric Bypass - Evaluation of Three Different Techniques.
Essam Abdel Galil, Alla Abbass Sabry**. Department of Surgery, Ahmed Maher Teaching Hospital*
and Ain Shams University**, Cairo, Egypt.17:18 30. Functional Gastric Bypass.
Francesco Furbetta, G. Gambinotti. Ospedale di Pescia, Pescia, PT, Italy.
20:00 Bus Transfer From Hotels to Chania.20:30 Opening Ceremony – Chania Port of Old Town.
21:00 Welcome Reception, Cocktail and Buffet Dinner (Port of Old Town).
23:30 Bus Transfer from Chania to Hotels.
Obesity Surgery, 11, 2001 355
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Session 1
Gastric Bypass
Moderators: Scott A. Shikora, U.S.A.; Guiseppe Marinari, Italy
13:00 31. A Comparative Study in Percentage of Weight Loss Between Laparoscopic and Open
Roux-en-Y Gastric Bypass.Constantine P. Spanos, Edward Salzmann, Christa M. Triglio PA-C, Scott A. Shikora. New England
Medical Center, Boston, MA, U.S.A.
13:12 32. Retrospective Comparison of Laparoscopic versus Open Gastric Bypass for Morbid Obesity.Anna Uskova, George Bentzel, Devora Hathaway BSN, Daniel Gagne, Raye Budway, Robert
Quinlan, Philip Caushaj. Department of Surgery, Temple University School of Medicine Clinical
Campus at the Western Pennsylvania Hospital, Pittsburgh, Pennsylvania, U.S.A.13:24 33. Laparoscopic Reoperation for Early Complications of Laparoscopic Gastric Bypass.
P. Papasavas, M.S. O’Mara, D. Heathaway, P. F. Caushaj, D. Gagne. Department of Surgery, The
Western Pennsylvania Hospital, Temple University Clinical Campus, Pittsburgh, Pennsylvania, U.S.A.13:36 34. The Art of Recycling: Laparoscopic Ventral Hernia Repair after Open Roux-en-Y Gastric
Bypass.
Marina S. Kurian, Daniel Marcus, Mitchell S. Roslin. Department of Surgery, Lenox Hill Hospital, New York, NY, U.S.A.
13:48 35. Laparoscopic Ventral Hernia Repair In Morbidly Obese after Open Roux-en-Y Gastric Bypass.
Piotr J. Gorecki, L.D. George Angus. Nassau University Medical Center, East Meadow, NY, U.S.A.
Session 2
Laparoscopic Restrictive Procedures
Moderators: Franz Aigner, Austria; Harry Frydenberg, Australia
14:00 36. Laparoscopic Adjustable Gastric Banding in Highly Obese.
F. Aigner, H. Weiss, H. Nehoda, H. Bonnati. University Hospital of Surgery, Department of General Surgery, Innsbruck, Austria.
14:12 37. Our Initial Steps in Laparoscopic Bariatric Surgery.
J. Bende, M. Ursu, M. Csiszár. Péterfy Hospital, Department of Surgery, Budapest, Hungary.14:24 38. Band Erosion and Slippage: Detecting and Avoiding Long-Term Complications.
J. A. Lopez Corvala, F. Cordero Guzman, A.A.A. Ortiz Lagardere. Laparoscopic Group of Baja
California, OBCT Control Center, Tijuana, Mexico.14:36 39. Use of BioEnterics Intragastric Balloon System for Obesity Treatment.
L.J.D.M. Schelfhout, J. Scherpenisse. Medical Centre Rotterdam Airport, D. Gabriels-Verweyen Body
Services Medical Centre Rotterdam Airport, The Netherlands.
Wednesday, September 5, 2001
3rd ISLOS (Concurrent Session)SAINT LUCAS HALL
356 Obesity Surgery, 11, 2001
Crete Program
14:48 40. 5-year Results of Laparoscopic Gastric Banding for Morbid Obesity.
M. K Müller1, M. Weber1, O. Schob2, L. Krähenbühl1, R. Schlumpf3, R.S.Hauser4.
1. University Hospital Zürich, Surgery; 2. Spital Limmattal, Visceral Surgery Schlieren; 3. Kantonspital
Aarau, Department of Surgery, Aarau; 4. Consultant for Nutrition, Zürich, Switzerland.
15:00-15:30 COFFEE BREAK
Session 3
Morbid Obesity: Management Options
Moderators: Jean-Marie Zimmerman, France; Jan Willem Greve, The Netherlands
15:30 41. Swedish Adjustable Gastric Band - Reoperation and Erosion.
Antelmo Sasso Fin. Hospital São Luiz, Brazil.
15:42 42. Lap-Band and Hiatus Hernia.
Francesco Furbetta, G. Gambinotti. Ospedale di Pescia, Pescia, PT, Italy.
15:54 43. Preliminary Results after Combination of using the HELIOGAST Band and the Two StepTechnique to Prevent Complications of the Laparoscopic Gastric Banding.
Salomon Benchetrit. Clinique Jeanne d’ Arc, Service de chirurgie digestive. Lyon, France.
16:06 44. Swedish Adjustable Gastric Banding in Morbidly Obese: Three years Experience.
Hany Aly Nowara. Cairo University Hospital and Mokattam Surgery Center, Egypt.
16:18 45. Laparoscopic Vertical Banded Gastroplasty and Roux-en-Y Gastric Bypass: Two Years Experience.
F. Cruz, J.L. Cruz, J. Canga, P. Gómez, J.I. Martínez, J.M. Menéndez, P. Yuste, P. Villarejo, E. Pérez,J. Moradiellos. 12 de Octubre University Hospital (Madrid); León Hospital (León).
Session 4
Long-Term Evaluation of Gastric Banding
Moderators: Marc Vertruyen, Belgium; Karl Miller, Austria
16:30 46. Esophageal Dilation After Laparoscopic Adjustable Gastric Banding: Myth or Reality?
Justin R. de Jong*, Cas H.J. Tiethof**, Robin Timmer***, Andre J.P.M. Smout****, Bert van
Ramshorst*. Depts. of Surgery*, Radiology** and Gastroenterology***, St. Antonius Hospital Nieuwegein, Dept. of Gastroenterology**** University Medical Centre Utrecht, The Netherlands.
16:42 47. Re-operations Following LASGB.
Ralph Peterli, Andrea Donadini, Peter Tondelli. Surgical Clinic, St. Claraspital Basel, Switzerland.
16:54 48. Evaluation of 150 patients with Laparoscopic Adjustable Gastric Banding.
Carlos Alberto Casalnuovo, Ezequiel Ochoa de Eguileor, Horacio Rozas, María Panzitta. Hospital de Clínicas, University of Buenos Aires, and Private Practice (CCO-Centro de Cirugía de la Obesidad),
Buenos Aires, Argentina.17:06 49. Long-Term Experience with Lap-Band System.
Marc Vertruyen. Europe St. Michel Clinic, Brussels, Belgium.17:18 50. Lap-Band, Safe and Effective Procedure: 4 year Follow-Up.
J.A. Lopez Corvala, F. Cordero Guzman, A.A.A. Ortiz Lagardere. Laparoscopic Group of Baja
California, OBCT Control Center, Tijuana, Mexico.
Obesity Surgery, 11, 2001 357
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20:00 BusTransfer From Hotels To Chania.
20:30 Opening Ceremony – Chania Port of Old Town.
21:00 Welcome Reception, Cocktail and Buffet Dinner (Port of Old Town).
23:30 Bus Transfer from Chania to Hotels.
Session 1
Vertical Banded Gastroplasty
Moderators: Andrew C. Jamieson, Australia; Bernhard J. Husemann, Germany
08:30 51. Assessment of Different Bariatric Operations: Data up to 5 years from the Italian Registry
Gastroplasty (LVBG): Intermediate Results of a Prospective, Comparative, Multicenter Trial.
N. Basso, F. Favretti*, M. Morino**, U. Parini***, G. Silecchia, A. Restuccia, U. Elmore, M. Toppino**.
Dipartimento di chirurgia “Paride Stefanini”, Policlinico “Umberto I ” Università “La Sapienza”, Roma;
Dipartimento Chirurgia Generale Osp S. Bortolo, Vicenza (ASL 6 Veneto), **Divisione Chirurgia,
Università di Torino; ***U.O. Chirurgia Generale, Ospedale Regionale Valle d’Aosta, Italy.
10:00-10:30 COFFEE BREAK
10:30-11:00 Distinguished Lecture. Introduction: George S. M. Cowan Jr, U. S. A.
The Physiology of Weight Loss and the Functioning of Bariatric Operations, Part II.
Nicola Scopinaro, Italy
Thursday, September 6, 2001
GENERAL SESSION IPPOCRATES HALL
358 Obesity Surgery, 11, 2001
Crete Program
Session 2
Surgical Treatment of Morbid Obesity and Super Obesity
Moderators: M.A.L. Fobi, U. S. A.; Rafael Capella, U. S. A.
11:00 57. 2010 Operations for Obesity in the Swedish SOS Study: Methods, Hospital Time and
Complications.
J. Hedenbro 1, I. Näslund2, G. Ågren2, A. K. Lindroos3, L. Sjöström3. Depts. of Surgery at Lund1 and Örebro2 University Hospitals and the SOS secretariat, Göteborg3, Sweden.
11:15 58. Bariatric Surgery for the Super Obese: What is the Best Operation?Joseph F. Capella, Rafael F. Capella. Hackensack University Medical Center, Hackensack, NJ, U.S.A.
11:30 59. Malabsorptive Gastric Bypass in Patients with Super Obesity: Comparative Study of Roux
Limb Length.
Robert E. Brolin, Lisa B. Lamarca MS, RD, Ronald P. Cody, EdD. St. Peter’s University Hospital and UMDNJ-RW Johnson Med Sch, New Brunswick, NJ, U.S.A.
11:45 60. Prospective Evaluation of the Fobi-Pouch Operation for Obesity: A Six-Year Follow-Up Report.
M.A.L Fobi. Center For Surgical Treatment Of Obesity, Tri-City Regional Medical Center, Hawaiian
Gardens, U.S.A.
12:00-12:30 POSTER VIEWING
12:30-14:00 LUNCH
Session 3
Special Lectures
Moderators: Mervyn Deitel, Canada; Latham Flanagan Jr, U. S. A.
14:00-14:30 From Paleosurgeon to CybersurgeonRafael Alvarez-Cordero, Mexico.
14:30-15:00 Current Status of Non-Adjustable Gastric Banding
Martin Fried, Czech Republic.15:00-15:30 Lessons Learned from 14 Years Experience with SAGB – Wireless Energy Transmission and
Remote Control: a Better, Safer and Advanced Band.
Peter Forsell, Sweden15:30-16:00 Is Surgery the Most Cost-Effective Treatment for Morbid Obesity?
David Kerrigan, UK.
16:00- 16:30 COFFEE BREAK
Session 4
Laparoscopic Gastric Banding
Moderators: Thomas P. Ricklin, Switzerland; Subhi Abu-Abid, Israel
16:30 61. Effects of Laparoscopic Gastric Banding on Body Composition, Metabolic Profile and
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Nutritional Status in Morbid Obesity: 12 Months Follow-Up.V. Giusti1, M. Suter2, E. Zysset1, E.Héraïef1, R.C. Gaillard1, P. Burckhardt1. Department of internal
Medicine1 and Surgery2, University Hospital – CHUV, Lausanne, Switzerland.16:45 62. Flexible Gastric Band: Success of Interdisciplinary Team-Work?
Thomas P. Ricklin1 Natascha Potoczna1, Grazyna Piec1, Rudolf Steffen2, F. Fritz. Horber1,2 1Clinic Hirslanden Zürich, 2OBEX-Institutes, Zürich and Bern, Switzerland.
17:00 63. Laparoscopic Gastric Banding: One Surgeon, 400 Cases, Results and Complications.
Paul Anderson. Oarlunga Hospital and Ashford Obesity Clinic, Adelaide, South Australia.17:15 64. Laparoscopic Vertical Gastric Banding – Five Years Experience.
Eliezer Avinoah, Leonid Landsberg, Solly Mizrahi. Surgery A, Soroka Medical Center, Faculty of
Health Sciences, Ben-Gurion University, Beer-Sheva, Israel.17:30 65. Safety and Feasibility of LAGB Following Previous Failed SRVG.
Subhi Abu-Abid, Ann Gorevich, Amir Szold. Surgery B, Bariatric Surgery and Advanced Laparo-scopic Surgery Unit, Tel Aviv, Suorasky Medical Center, Tel Aviv, Israel.
17:45 66. Laparoscopic Treatment of Complications after Vertical Banded Gastroplasty.Karl Miller, Emanuel Hell. Krankenhaus Hallein and Ludwig Boltzmann Institut für Gastroenterologie, Hallein, Salzburg, Austria.
Adjourn
Session 1
Malabsorptive Procedures
Moderators: Robert Brolin, U. S. A.; Roberto M. Tacchino, Italy
08:30 67. Contraceptive Therapy after Biliopancreatic Diversion in the Treatment of Morbid Obesity.
R. Ceulemans, E. Gerrits, L. Hendrickx, E. Totté, R. Van Hee. Academic Surgical Centre Stuivenberg, Antwerp, Belgium.
08:42 68. Short-Term Comparison of “Long-Limb” Roux-en-Y Gastric Bypass versus Biliopancreatic Diversion with “Duodenal Switch”.
T. Daskalakis, J. Nicastro, H. Mcmullen, S. Bianchi, M. Pagala, G. Coppa, J.N. Cunningham, J.Macura. Staten Island University Hospital, Staten Island, NY and Maimonides Medical Center, Brooklyn, NY, U.S. A.
08:54 69. Biliopancreatic Diversion (BPD) for Severe Obesity: Comparison at One Year of Scopinaro’s BPD and BPD with Transitory Gastroplasty Preserving Duodenal Bulb.F. Mittempergher, E. Di Betta, C. Casella, B. Salerni. Chair of General Surgery, University of Brescia, Italy.
09:06 70. Comparison of Micronutrient Deficiencies after Roux-en-Y Gastric Bypass and Biliopancreatic Diversion with Roux-en-Y Gastric Bypass in Morbid Obesity.
George Skroubis*, George Sakellaropoulos**, Nancy Mead*, George Nikiphoridis**, Fotis Kalfarentzos*. Nutrition Support and Morbid Obesity Clinic, Surgical Department* and Department of
Medical Physics**, School of Medicine, University of Patras, Greece.
Thursday, September 6, 2001
GENERAL SESSION (Concurrent)SAINT LUCAS HALL
360 Obesity Surgery, 11, 2001
Crete Program
09:18 71. Jejunoileal Bypass – Status 25 Years after the Operation.
Villy Våge1, Jan Helge Solhaug2, Asgaut Viste3, Arnold Berstad4. Department of Surgery, Førde1, Deakon Hospital, Oslo2, Department of Surgery3 and Department of Medicine4, Haukeland University
Hospital, Bergen, Norway.09:30 72. Improvement in Insulin Levels and Insulin Resistance after Biliopancreatic Diversion in
Morbid Obesity With and Without Diabetes Type II.Maria Laura Cossu, Enrico Fais, Matteo Ruggiu, Claudio Sparta, Franca Cossu, Giuseppe Noya.Department of Emergency Surgery, University of Sassari, Italy.
09:42 73. Choice of Optimal Bariatric Procedure in the Treatment of Morbid Obesity.
A. S. Lavryk, V-F. Sayenko, O. S. Tyvonchuk, O. P. Stetsenko, T. V. Masurak. Institute of Surgery and
Transplantology, Kyiv, Ukraine.
10:00–10:30 COFFEE BREAK
10:30–12:30 Workshop: “Gastric Pacing”, sponsored by Transneuronix.
12:30–14:00 LUNCH
14:00-16:00 Workshop: “Innovation, Support and Long-term Experience: a Review of the LAP-BAND®
System, sponsored by BioEnterics.
16:00- 16:30 COFFEE BREAK
Session 2
Video
Moderators: Aniceto Baltasar, Spain; Ilan Charuzi, Israel
16:30 74. Early Experience with Laparoscopic Biliopancreatic Diversion (LBPD).
Roberto M. Tacchino, Maurizio Foco, Gianni Greco, Marco Castagneto. Department of Surgery,
Catholic University SH, Rome, Italy.16:42 75. Laparoscopic Biliopancreatic Diversion – Technique and Initial Results.
Dyker Paiva, Lucineia Bernardes, Livio Suretti. Surgical Department, Mater Dei Hospital, Belo
Horizonte, Brazil.16:54 76. Laparoscopic Scopinaro with Duodenal Switch and Associated Crural Repair and
Cholecystectomy.
George A. Fielding. Wesley Hospital and Royal Brisbane Hospital, Brisbane, Australia.
17:42 80. The Pars Flaccida Technique in LASGB-Operation with New 11cm Lap-Band®.
Ralph Peterli, Peter Tondelli. Surgical Clinic, St. Claraspital, Basel, Switzerland.
Adjourn
Obesity Surgery, 11, 2001 361
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Session 1
Gastric Banding
Moderators: Mitiku Belachew, Belgium; Patrice Lointier, France
8:30 81. Gastric Pouch Dilation following LAGB® System Procedure: the Italian Experience.
L. Angrisani, F. Furbetta, S. B. Doldi, N. Basso, M. Lucchese, M. Giacomelli, M. Zappa, E. Lattuada,
L. Di Cosmo, A. Veneziani, G. U. Turicchia, F. Favretti, M. Alkilani, P. Forestieri, G. Lesti, F. Puglisi, M.Toppino, F. Campanile, F. D. Capizzi, C. D’Atri, L. Scipioni, C. Giardiello, N. Di Lorenzo, S. Lacitignola,
M. Belvederesi, B. Marzano, G. Bernante, A. Luppa, V. Borrelli, M. Lorenzo. Italian Group for Lap-Band GILB, Naples, Italy.
8:45 82. Long-Term Results of Laparoscopic Adjustable Gastric Banding in three Major Centres in Belgium.
M. Belachew*, C. Desaive**, P. Belva****Chr Huy, **Chu Liege, ***Chu Charleroi, Belgium.
9:00 83. Lap-Band, Prevention of Slippage: Series of 1410 Patients: Switching from the 9.5/10.0 Band to the New Generation 11.0 Band.
Jean-Marie Zimmermann, Michel Blanc, Pierre Mashoyan, Érick Zimmermann, Jean-Marc Grimaldi.Clairval Private Hospital Center, Marseille, France.
9:15 84. Late Outcome of Adjustable Gastric Banding for Surgical Treatment of Morbid Obesity.Cornelius Doherty, James W. Maher, Debra Heitshusen, RN, BSN. Department of Surgery, School of
Medicine, University of Iowa, Iowa City, Iowa, U.S.A.
9:30 85. Early Results with the Heliogast Band.
Marc Vertruyen. Europe St. Michel Clinic, Brussels, Belgium.
9:45 86. Laparoscopic Experience with a New Adjustable Gastric Band.
Patrice Lointier. Private Practice, Clermont-Ferrand, France.
10:00-10:30 COFFEE BREAK
10:30-11:00 Presidential Address: Introduction: Emanuel HellObesity Surgery – Pain, Privilege and Responsibility.
Andrew C. Jamieson, Australia
Session 2
Gastric Pacing
Moderators: Henry Buchwald, U. S. A.; Ingmar Näslund, Sweden
11:00 87. Pacing the Stomach: Our Experience on Two Obese Patient Populations.
V. Cigaina*, A. Saggioro*** Unit of Digestive Surgical Electrophysiology O. C. “Umberto I” Mestre-
Mestre-Venezia, Italy.11:15 88. Implantable Gastric Stimulation: Preliminary Results in France.
Jerome Dargent. Polyclinique de Rillieux, Private Practice, France.11:30 89. Successful Use of Endoscopic Ultrasound (EU) to Verify Lead Placement for the Implantable
Gastric Stimulator (IGS™)
Scott A. Shikora, Tamsin A. Knox, Laurence Bailen, Frederick J. Doherty, Christa M. Trigilio, PA-C.
New England Medical Center, Boston, MA, U. S. A. .11:45 90. Gastric Pacing versus Gastric Banding in Morbid Obesity - the Magdeburg Experience.
S. Wolff, C Gerards *, H. Lippert, P. Malfertheiner*. Dept. Surgery, Dept. Gastroenterology, University of Magdeburg, Germany.
12:00-12:30 POSTER VIEWING
12:30-14:00 LUNCH
Session 3
Special Presentations
Moderators: George S. M. Cowan Jr, U. S. A.; David Kerrigan, U. K.
14:00-14:30 Lap-Band System®: the Choice of the Patient.
George A. Fielding, Australia; Roberto Rumbault, Mexico.14:30-14:50 Progress in Bariatric Surgery, OBESITY SURGERY Journal and Report on IFSO.
Mervyn Deitel, Canada.14:50-15:00 IFSO Meeting in 2002, São Paulo.
Arthur B. Garrido Jr, Brazil.
Session 4
Adjustable Gastric Banding
Moderators: Andreas Glättli, Switzerland; Carlos F. Escalante, Spain
15:00 91. Comparative Study Between Lap-Band and Swedish Adjustable Gastric Banding.J. M. Fabre, D. Nocca, M. C. Lemoine, C. Vacher, C. de Seguin, E. Renard, J. Domergue. Hôpital Saint
Eloi, Montpellier,France.15:15 92. Swedish Adjustable Gastric Band: Principles of an Optimal Band Adjustment.
Hans Triaca-Bernasconi, Guido Stirnimann, Christian Klaiber. Hospital of Aarberg, Switzerland.15:30 93. A Comparison of Complication Rates in 151 Cases of Lap-Banding and 174 Cases of the
Swedish Adjustable Gastric Banding.
James D. Ritchie. Keyhole Surgery Centre, Sydney, Australia.
15:45 94. Reduction of Obesity-Related Co-Morbidity after Laparoscopic Gastric Banding (SAGB®).
A. Glättli,1,3 G. Stirnemann2, S. Schlatter1, R. Stouthandel1, H. Triaca2, Ch. Klaiber2. Zieglerspital
James D. Ritchie. Keyhole Surgery Centre, Sydney, Australia.
17:15 98. Our Bariatric Surgery Experience with Bilio-intestinal Bypass.
Santo Bressani Doldi, G. Micheletto, M. Perrini. Cattedra di Chirurgia Generale dell’Università degli
Studi di Milano, Istituto Clinico Sant’Ambrogio; Centro per la Farcomacoterapia delle Malattie
Nutrizionali e Metaboliche “E. Genovese e R. Klinger” (Direttore Scientifico: Prof. S.B. Doldi), Milan,
Italy.
17:30 99. Intestinal Obstruction after Malabsorptive Procedures: Still a Potentially Deadly
Complication.
Kenneth B. Jones Jr. Christus Schumpert Health System, Shreveport, LA, U.S.A.
17:45 100. Malabsorptive Surgery in the Therapy of Superobesity: Reasons to Choose Between the
“DOC” B.P.D Technique and its Variants, Gastric Bypass and Intestinal Bypass.
C. Vassallo, M. Andreoli, G. Berbiglia, A. Pessina, D. Savioni. Private Practice, “Morelli” Clinic, Pavia,
Italy.
20:30 Bus Transfer to “Metoxi” Restaurant
21:00 Cretan Night
24:00 Bus Transfer to Hotels
364 Obesity Surgery, 11, 2001
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Session 1
Gastric Bypass
Moderators: Kenneth B. Jones Jr, U. S. A.; Emanuel Hell, Austria
08:30 101. Flexible Endoscopy in the Management of Patients Undergoing Roux-en-Y Gastric Bypass.
Bruce Schirmer, Anna Miller, RN. University of Virginia Health Sciences Center, Charlottesville, VA,
U.S.A.08:42 102. Objective Assessment of the Effect of Laparoscopic Gastric Bypass on Esophageal pH and
Motility in Morbidly Obese Patients with GERD.Emma J. Patterson, Yashodhan S. Khajanchee, Lee L. Swanstrom. Legacy Health System, Portland,
Oregon, U.S.A.
08:54 103. Prophylactic Cholecystectomy with Gastric Bypass Operation - Incidence of Gallbladder Disease.
Daniel Igwe Jr, Malgorzata Stanczyk, Basil Felahy, Hoil Lee, E. James , Nicole Fobi, MAL Fobi.Center for Surgical treatment of obesity, Hawaiian Gardens, CA, U.S.A
09:06 104. Initial Experience with Open and Laparoscopic Gastric Bypass in Naples.
Luigi Angrisani, Vicenzo Borelli, Michele Maresca, Michele Lorenzo, Gaetano Cimmino, Monica Ciannella, Monica Giuffre, Annalicia Mozzillo. Unit of Endoscopy Surgery, “S. Giovanni Bosco”
Hospital Naples.09:18 105. Leakage after Roux-en-Y Gastric Bypass.
A. Westling, M. D. Sundbom, S. Gustavsson. University Hospital, Uppsala, Sweden.
09:30 106. A New Technique for Making a Fully Stapled Divided Gastric Bypass: 1-3 Year Results.J. Hedenbro, S. F. Frederiksen, M. Flemming. Department of Surgery at Lund University Hospital,
Lund, Sweden.09:42 107. Laparoscopic Gastric Bypass: Results in 76 Patients.
Hans Lönroth, Torsten Olbers, Lars Lundell. Department of Upper GI-Surgery, Sahlgrenska
University Hospital, Gothenburg, Sweden.
10:00-10:30 COFFEE BREAK
10:30-12:30 Workshop: “Remote Control Gastric Banding”, sponsored by Obtech.
12:30-14:00 LUNCH14:00-16:00 Workshop: “A New Era for Laparoscopic Antiobesity Procedures, with the Use of EndoGIA
Universal® and Ligasure® Laparoscopic Vessel Sealing System”, sponsored by Tyco.
16:00- 16:30 COFFEE BREAK
Friday, September 7, 2001
GENERAL SESSION (Concurrent)SAINT LUCAS HALL
Obesity Surgery, 11, 2001 365
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Session 2
Video Session
Moderators: James A. Sapala, U. S. A.; Antonio Cascardo, Argentina
16:30 108. Micropouch Gastric Bypass.
James A. Sapala, Michael H. Wood, Michael P. Schuhknecht, Thomas M. Flake Jr, M. Andrew Sapala.
St. John Weight Loss Institute, St. John Detroit Riverview Hospital, Detroit, MI, U. S. A.16:42 109. Laparoscopic Gastric Bypass Exactly Reproduces the Open Technique.
I. Díez del Val, C. Martínez Blázquez , J.M. Vitores López , V. Sierra Esteban, J. Valencia Cortejoso
J.D. Sardón Ramos. Hospital Txagorritxu, Vitoria-Gasteiz, Spain.16:54 110. Big Guys – Lap Banding for Super Obesity.
George A. Fielding. Wesley Hospital and Royal Brisbane Hospital, Brisbane, Australia.17:06 111. Laparoscopic Gastric Bypass with Manual Anastomosis.
Antonio Cascardo, Silvio Albarracín, Adrian Alvarez. IMETCO (Multidisciplinary Institute Specialized in the Treatment and the Surgery of Obesity), Buenos Aires, Argentina.
17:18 112. Implantable Stimulator (IGSTM) for Treatment of Severe Obesity: Initial Experience in Greece.
J. Melissas, G. Shoretsanitis, J. Michalakis, H. Sonidas, G. Georgopoulou. Bariatric Unit, Dept. of Surgical Oncology, University Hospital, Heraklion, Crete, Greece.
17:30 113. The Use of a Nitinol U-CLIP (Coalescent Surgical Inc) for Advanced Laparoscopic Procedures Including Gastric Bypass.
Marina S. Kurian, Valavanur Subramanian, Mitchell S. Roslin. Department of Surgery, Lenox Hill Hospital, New York, NY, U. S. A. .
17:42 114. Laparoscopic Long Vertical Gastric Stapling ± Sleeve Gastrectomy for the Treatment of Morbid Obesity.
Simon P.L. Dexter, Michael J. McMahon, Nikos Georgopoulos. Leeds Institute for Minimally Invasive Therapy, The General Infirmary, Leeds, UK.
20:30 Bus Transfer to “Metoxi” Restaurant 21:00 Cretan Night 24:00 Bus Transfer to Hotels
Miyazawa2, Takenori Ochiai2. J. A. Marronier Medical Center, Shimotsuga General Hospital1
Department of Surgery, Chiba University School of Medicine2, Japan.09:12 116. Gastroenteric Bypass: Modification of the Technique.
Antonio Cascardo, Silvio Albarracín, Adrian Alvarez. IMETCO (Multidisciplinary Institute Specialized in the Treatment and the Surgery of Obesity), Buenos Aires, Argentina.
09:24 117. A Comparative Study Between Four Bariatric Procedures: Is there an Ideal Procedure yet?
Khaled Gawdat. Ain Shams School of Medicine, Cairo, Egypt.
09:36 118. Combined Surgery for Morbidly Obese with Reflux Esophagitis.
Alaa Abbass S. Moustafa, Essam Abd el Gelil. Ain Shams University and Ahmed Maher Teaching Hospital, Cairo, Egypt.
09:48 119. Electrogastrography in Morbidly Obese Patients.
Francois van Dielen*, Freek Daams**, Bas de Cock*, Robert-Jan Brummer**, Jan Willem Greve*.
Dept. of General Surgery* and Gastroenterology**, University Hospital Maastricht, The Netherlands.
Session 2
Gastric Banding
Moderators: Martin Fried, Czech Republic; Andriy Lavryk, Ukraine
10:00 120. Is the Laparoscopic Rebanding for Pouch Complications after Laparoscopic Gastric Banding
the Right Choice?.M. Weber1, M. K. Müller1, F. Horber2, L. Krähenbühl, R. S. Hauser3. 1. University Hospital , Clinic for Visceral Surgery, Zürich; 2. Klinik Horslanden, Zürich; 3. Consultant for Nutrition, Zürich, Switzerland.
10:12 121. Lap-Band Erosion: Incidence and a Way of Treatment.
Erik Niville. Ziekenhuis Oost Limburg, Genk, Belgium.
10:24 122. Laparoscopic Adjustable Gastric Banding: Personal Experience.
Marcello Lucchese, Andrea Valeri, Giovanni Cantelli, Ingrid Paulin, Saverio Reddavide, Domenico
Borrelli. Dept. of Gen. and Vasc. Surgery, Policlinico di Careggi, Florence, Italy.10:36 123. Adjustable Silicone Gastric Banding for Revision of Failed Gastric Bariatric Procedures.
Shlomo Kyzer, Aznat Raziel, Ofer Landau, Alexander Matz, Ilan Charuzi. Department of Surgery “B”, E. Wolfson Medical Center, Holon, Israel.
10:48 124. Quality of Life following Laparoscopic Gastric Banding for Obesity.
Reyad Al-Ghnaniem*, Andrew Dettrick§, George A. Fielding§, Ameet G. Patel**. King’s College Hospital, London, UK; §Wesley Medical Centre, Brisbane, Australia.
11:00-11:30 COFFEE BREAK
Session 3
Intragastric Balloon
Moderators: Jerome Dargent, France; Jean-Luis Allé, France
11:30 125. Intragastric Balloon Technique for the Treatment of Severe Obesity: Short-term and Mid-Term Follow-Up of the First 52 Patients in Argentina.
D. Raemdonck*, P. Belva*, P. Rotsaert*, J. C. Lefebvre*, M. Takkiedine*, P. Vaneukem*, A. Bailly **.
Department of Digestive Surgery*, Department of Clinical Nutrition**, CHU Charleroi, Charleroi, Belgium.
11:54 127. Are Intragastric Balloons Useful in the Management of Obesity?
A. E. E. Elewaut, A. Z. Groeninge. Campus Onze-Lieve-Vrouw, Department of Gastroenterology, Belgium.
12:06 128. The new Intragastric Balloon (BIB): a French experience of 23 cases, with Adjunction of aHigh-Protein Diet
Jerome Dargent. Laurence Poulain, Dietitian. Private practice, Polyclinique de Rillieux. Rillieux-la-pape, Cedex, France.
12:18 129. Treatment of Morbid Obesity with Intragastric Balloon (BIB) in Association with Diet.
Santo Bressani Doldi, G. Micheletto, M. Perrini, M.C. Librenti*, S. Rella*. Cattedra di Chirurgia
Generale dell’Università degli Studi di Milano, Istituto Clinico Sant’Ambrogio, Centro per la Farcomacoterapia delle Malattie Nutrizionali e Metaboliche “E. Genovese e R. Klinger”, *Unità di
Malattie Metaboliche, Istituto Clinico San Siro, Milan, Italy.
Session 4
Novelties in Bariatric Surgery
Moderators: Anna Maria Wolf, Germany; Ahmed Zayed, Kuwait
12:30 130. Preliminary Report on Surgical Intervention on Patients with BMI>32 but <40 without Life-
Threatening Comorbidities.
MAL Fobi. Center For Surgical Treatment of Obesity, Tri-City Regional Medical Center, Hawaiian
Gardens, CA, U.S.A.12:42 131. Tissue Adhesive for Bariatric Surgery.
Alan C. Roberts*, Steve Pollard**. *Academic Surgical Unit, University of Hull Medical School, England; **Department of Surgery, St James’s Hospital, Leeds, England.
12:54 132. Correlation Between Fat Distribution, Hyperlipidemia, Diabetes and Coronary Heart Disease In Morbidly Obese Patients.
Anna Maria Wolf, Burkhard Kortner, Hans Werner Kuhlmann, Ulrike Beisiegel*. General Surgery, Evangelisches und Johanniter Klinikum Duisburg, Dinslaken, Oberhausen gGmbH, Germany.
*Medical Clinic, University Hospital Hamburg-Eppendorf, Germany.13:06 133. Four-Year Evaluation of Three Surgical Techniques.
Rafael Alvarez-Cordero, V. E. Aragón, R. J. Montoya, A. O. Sandoval, D. A. Toledo. Hospital Angeles del Pedegral, México City, México.
13:18 134. From Open to Laparoscopic Gastric Bypass.
I. Díez del Val, C. Martínez Blázquez, J. D. Sardón Ramos, J. M. Vitores López, V. Sierra Esteban,
J. Valencia Cortejoso. Hospital Txagorritxu, Vitoria-Gasteiz, Spain.
368 Obesity Surgery, 11, 2001
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Session 1
Adjustable Gastric Banding
Moderators: Rafael Alvarez-Cordero, Mexico; Mustafa Taskin, Turkey
09:00 135. Laparoscopic Gastric Banding for the Massively Obese.
George A. Fielding. Wesley Hospital and Royal Brisbane Hospital, Brisbane, Australia.09:12 136. How Can a New Technique for Laparoscopic Placement of the Adjustable Gastric Band
(Lap-band) Prevent Slippage?
D. Wagner, R. Weiner,* U. Winterberg, H. Bockhorn. Chirurgische Klinik Krankenhaus Nordwest Frankfurt am Main und Chirurgische Klinik Krankenhaus Sachsenhausen, Frankfurt am
Main*, Germany.
09:24 137. Influence of Gastric Perforation, Simultaneous Cholecystectomy and Wound Infection on Late Postoperative Complications.
Christine Stroh, Haralad Schramm, Ulrich Hohmann. Wald-Klinikum Gera gGmbH i.G.,Departement
für Allgemeine Viscerale und Kinderchirurgie, Gera, Germany.09:36 138. Is a Routine Gastrografin® Swallow Following Laparoscopic Gastric Banding Mandatory?
H. Nehoda, K. Hourmont, R. Mittermair, M. Lanthaler, T. Sauper, R. Peer*, F. Aigner, H. Weiss.Department of General Surgery/Department of Radiology*, University Hospital of Innsbruck, Austria.
09:48 139. Motility Disorders of the Esophagus following Adjustable Gastric Banding Operations.
F. Schmoeller, G. Boehm*, K. Krichbaumer, M. Sengstbratl, R. Fuegger, F. Miess*. Department for Surgery, Department for Radiology*, Elisabethinen Hospital, Linz, Austria.
Session 2
Co-morbidities
Moderators: Yury I. Yashkov, Russia; Spiros Papavramides, Greece
10:00 140. Control and Regression of Type II Diabetes after Bariatric Surgery
G. Vargas *, H. Cardoso*, M. Monteiro*, A. Sergio**, F. Pichel*, I. Pereira, M.J. Santos***,
C. Cunha***, F. Bravo ***, Carvalho-Santos***, H. Ramos*. Department of Endocrinology, Diabetes and Metabolism*; Department of Surgery 2** and Department of Clinical Chemistry ***, San Antonio
General Hospital, Porto, Portugal.
10:12 141. Behavior of Insulin Resistance and Leptin Levels after Bariatric Surgery.Bruno Geloneze, José Carlos Pareja, Enrico Repetto, Roberto Teixeira, Silka Geloneze, Marcos
Tambascia, UNICAMP- State University of Campinas, Brazil.
10:24 142. Improvement of Obesity-Associated Co-Morbidity after Bariatric Surgery: Follow–up of 18 Patients During 24 Months.
H. Cardoso, M. Monteiro, G. Vargas, A. Sergio, F. Pichel, I.A. Pereira, M.J. Santos, C. Cunha, F. Bravo,
Carvalho-Santos, H. Ramos. Depts. of Endocrinology, Diabetes and Metabolism, Surgery 2 and
Saturday, September 8, 2001
GENERAL SESSION (Concurrent)SAINT LUCAS HALL
Obesity Surgery, 11, 2001 369
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Clinical Chemistry, San Antonio General Hospital Porto, Portugal.
10:36 143. Reducing Risks in Bariatric Surgery: Is Sibutramine Useful?
Enrico Repetto, Bruno Geloneze, José Carlos Pareja, Roberto Teixeira, Marcos Tambascia. UNI
CAMP-State University of Campinas, SP, Brazil.
10:48 144. Insulin Resistance in the Severely Obese and Links with Metabolic Co-morbidities.
Richard S. Stubbs, Kusal Wickremesekera. Wakefield Gastroenterology Centre, Wellington, New
Zealand.
11:00-11:30 COFFEE BREAK
Session 3
Research and Surgical Treatment of Obesity
Moderators: Antonio Sergio Bastos Silva, Portugal; Richard S. Stubbs, New Zealand
11:30 145. Effect of Excessive Weight Loss on Immune-Regulatory Mechanisms in Morbidly Obese
Patients.
H. Weiss, H. Schwelberger, J. Klocker, B. Labeck, H. Nehoda, F. Aigner, G. Weiss. Departments of General Surgery and Internal Medicine, University Hospital Innsbruck, Austria.
11:42 146. Normal Enoxoparin Doses Give too Low Plasma Values in Morbid Obesity.
S. G. Frederiksen, L. Norgren, J. L. Hedenbro. Department of Surgery, Lund University Hospital, Lund,
Sweden.
11:54 147. Safety of Bilateral Vagus Nerve Stimulation for Obesity.
M. S. Roslin, M. Kurian, M. Genovesi, F. Moody. Lenox Hill Hospital, New York, NY; University of Texas
at Houston, Houston, TX, U.S.A.
12:06 148. Surgical Treatment of Obesity by Gastric Banding.
Jean-Jacques Sala. Clinique Clement Drevon, Dijon, France.
12:18 149. Heliogast vs Lap-Band Gastroplasty.
Jacques Himpens, Guido Leman. St. Blasius Hospital, Dendermonde, Belgium.
Session 4
Vertical Banded Gastroplasty
Moderators: George Schoretsanitis, Greece; Shrihari Dhorepatil, India
12:30 150. Weight Loss Results of Vertical Banded Gastroplasty in Superobese Patients.
Yury I. Yashkov, Tatiana A. Oppel, Oleg G. Skipenko. Russian Research Center of Surgery, Moscow,
Russia.
12:42 151. Vertical Banded Gastroplasty: A 12-year Experience.
A. l. Papakonstantinou, P. Alfaras, V. Komessidou, J. Terzis, P. Moustafelos, S. Gourgiotis,
T. Anastasiou, E. Niakas, E. Mamplekou, E. Hadjiyannakis. 1st Surgical Department and
Transplantation Unit of the Gen. Hospital of Athens “EVANGELISMOS”, Athens, Greece.
12:54 152. Vertical Banded Gastroplasty with Silicone Ring: First Experience in Romania for the
Surgical Treatment of Severe Obesity.
Romeo Florin Galea, A. Ciule, D. Mircioiu, Dana Pintea, Florinela Galea. The Second Surgical Clinic,
370 Obesity Surgery, 11, 2001
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UMF, Cluj-Napoca, Romania.
13:06 153. Modified VBG for Morbid Obesity - An Early Indian Experience.
Shrihari Dhorepatil. Jahangir Hospital Center, Pune, India.13:18 154. Ten Years of Experience of VBG in Open Surgery.
Stefano Cariani, D. Nottola, G. Vittimberga, S. Grani, A. Lucchi, F. Mancini, E. Amenta. Università di Bologna, Dipartimento di Scienze Chierurgiche ed Anestesiologiche, Centro Studi diterapia
P1. Optimal Timing of Incisional Hernia Repair and Laparoscopic Gastric Banding.H. Bonatti, W. Kirchmayr, H. Nehoda, F. Aigner, P. Kronberger, H. Weiss. Dept of General Surgery, University
Hospital, Innsbruck, Austria.P2. Regression of Hyperandrogenism in Obese Females Submitted to Bariatric Surgery.
M. Monteiro, H. Cardoso, G. Vargas, F. Pichel, I. A. Pereira, A. Sergio, M. J. Santos, C. Cunha, F. Bravo, Carvalho-Santos, H. Ramos. Depts. of Endocrinology, Diabetes and Metabolism, Surgery 2 and Clinical Chemistry. San Antonio General Hospital, Porto, Portugal.
P3. Effect of Massive Weight Loss in Glucose Tolerance and Ghrelin, a Novel Gut Hormone.Victor Pilla, José Carlos Pareja, Enrico Repetto, Bruno Geloneze, Silka Geloneze, Marcos Tambascia. UNI
CAMP, State University of Campinas, SP, Brazil.P4. Relationship Between Ghrelin and Leptin in Obese Subjects.
José Carlos Pareja, Victor Pilla, Bruno Geloneze, Enrico Repetto, Silka Geloneze, Marcos Tambascia. UNICAMP, State University of Campinas, SP, Brazil.
P5. Type-2 Diabetes, Glucose Control and Insulin Resistance following Massive Weight Loss.
Bruno Geloneze, José Carlos Pareja, Enrico Repetto, Silka Geloneze, Roberto Teixeira, Marcos Tambascia.UNICAMP, State University of Campinas, SP, Brazil.
P6. Inflammatory Markers, Insulin Resistance and Weight Loss following Bariatric Surgery.Bruno Geloneze, José Carlos Pareja, Enrico Repetto, Roberto Teixeira, Silka Geloneze, Marcos
Tambascia. UNICAMP, State University of Campinas, SP, Brazil.P7. Insulin Resistance and Uricemia in Severely Obese Subjects Following Bariatric Surgery.
Bruno Geloneze, José Carlos Pareja, Enrico Repetto, Silka Geloneze, Marcos Tambascia. UNICAMP, State University of Campinas, SP, Brazil.
P8. Integrated Surgical Approach to Obesity.
George A. Fielding. Wesley Hospital and Royal Brisbane Hospital, Brisbane, Australia.P9. Laparoscopic Adjustable Gastric Banding in Super Morbid Obese: an Egyptian Experience.
Hany Aly Nowara. Assistant Professor Of Surgery, Cairo University, Hospital and Mokattam Surgery Center, Cairo, Egypt.
P10. Bariatric Surgery for Children and Adolescents: What are the Indications?
Khaled Gawdat, Ashraf Kabesh. Ain Shams School of Medicine, Cairo, Egypt.P11. The Evaluation of Etiology, Risk Ractors, Complications and Benefit, Using the Data Base “Obesity
2.0” for Laparoscopic Bariatric Surgery.D. Wagner, R. Weiner, U. Winterberg, H. Bockhorn. Department of Surgery, KH Nordwest, Frankfurt a.M,
Germany.P12. Lap-Band - persisting Good Result with Slipped Band by Modified Technique.
George A. Fielding. Wesley Hospital and Royal Brisbane Hospital, Brisbane, Australia.P13. The Effects of Long Limb Gastric Bypass on Monocyte Dysfunction in Morbid Obesity.
L. D. G. Angus, D. R. Cottam, D. Fahmy, G. W. Shaftan, P. A. Schaefer. Nassau University Medical Center,
Department of Surgery, East Meadow, New York, U.S.A.
P14. Abnormal Videofluoroscopic Findings in Patients After Laparoscopic Gastric Banding.G. Boehm1, F. Schmoeller2, K. Kriechbaumer2, F. Miess1, R. Függer2. 1Department of Radiology, 2Department of Surgery, Elisabethinen Hospital Linz, Austria.
P15. Esophago-Gastric Laparoscopic Placement of Lap-Band for Morbid Obesity: Considerations After
the First 80 Cases.
Sergio Boschi, L. Fogli, A. Cuppini*, M. Brulatti, P. Patrizi, V. Papa, M. Di Domenico, F. D. Capizzi. General Surgery and *Internal Medicine, Bellaria Hospital, Bologna, Italy.
P16. Apolipoprotein E and CIII in Patients with Obesity-Related Phenotype BMI after Bariatric Surgery.J. C. Cagigas (*), Alfredo Ingelmo (*), R. Hernandez-Estefania,, D. Gonzalez-Lamuño, M. Garcia-Ribes, S.
Revuelta (*), C. Escalante. Nutrition and Cardiovascular Risk Unit, University of Cantabria, General Surgery.Hospital Universitary Valdecilla, Hospital Sierrallana (*), Spain.
P17. Obesity Surgery Pitfalls and Morbidity at 10-year Follow-Up with Vertical Banded Gastroplasty.
J. C. Cagigas(*), Alfredo Ingelmo (*), R. Hernandez-Estefanía, F. Olmedo, S. Revuelta (*), E. Martino, C. F.Escalante. Hospital Valdecilla, Hospital Sierrallana(*), University of Cantabria. Spain.
P18. Small Bowel Obstruction following Long Limb Roux-en-Y Gastric Bypass for Morbid Obesity:Presentation of 3 Cases.
T. Daskalakis, J. Nicastro, H. Mcmullen, G. Coppa, J. N. Cunningham, J. Macura. Maimonides Medical Center, Brooklyn, NY and Staten Island University Hospital, Staten Island, NY, U.S.A.
P19. The Use of Endostaplers in the Reconversion of a Failed Vertical Banded Gastroplasty to
Biliopancreatic Diversion (Scopinaro).C. F. Escalante, A. Domínguez-Diez , A. Ingelmo, F. Olmedo, M. G. Fleitas. Institute of Digestive Diseases.
Hospital U, “Marqués de Valdecilla”, Santander, Spain.P20. Quality of Life after Roux-en-Y Gastric Bypass.
Joel Faintuch, Priscilla L. R. C. Machado, Monica A. Rudner, Arthur B. Garrido Jr , Luiz V. Berti, Marlene M.Silva, J.J. Gama-Rodrigues. Obesity Surgery Group, Hospital das Clinicas, Sao Paulo, SP, Brazil.
P21. Response of Comorbidities to Roux-en-Y Gastric Bypass.
Joel Faintuch, Monica A. Rudner, Priscilla L. R. C. Machado, Arthur B. Garrido Jr, Marcelo R. Oliveira, J.J.Gama-Rodrigues. Obesity Surgery Group, Hospital das Clínicas, Sao Paulo, SP, Brazil.
P22. New Positioning of the Port System.Francesco Furbetta, G. Gambinotti. Ospedale di Pescia, Pescia, PT, Italy.
P23. Minor Late Complication of Roux-en-Y Gastric Bypass.Sergio Z. Gil, Monica A. Rudner, Priscilla L. R. C. Machado, Joel Faintuch, Arthur B. Garrido Jr, J.J. Gama-
Rodrigues. Obesity Surgery Group, Hospital das Clinicas, Sao Paulo, SP, Brazil.
P24. Lowering the Complication Rate in LAP-BAND Procedures by Cooperation and Experience.Pavol Holéczy1, Vladimír Medveck2, Holéczyová Albeta1, Linhartová Nadeda1. 1Surgical Department,
Railway Hospital, Bratislava, Slovakia; 2Surgical Department, VS Hospital, Koice, Slovakia.P25. Prophylaxis of Thromboembolism in Bariatric Surgery.
A. S. Lavryk, V. F. Sayenko, O. P. Stetsenko, O. S. Tywonchuk, V. J.Smorzhevsky, O. F. Bubalo. Institute of Surgery and Transplantology, Kyiv, Ukraine.
P26. Body Composition Studies in Obese Children.
Renata B. A. Leme, Marilisa S. Froes, Eduardo Meirelles, Ari L. Cardoso, Andrea Nascimento, Cristiane A.R. Charles, Arthur B. Garrido Jr, Joel Faintuch. Obesity Group, Children’s Institute and Hospital das
Clinicas, Sao Paulo, SP, Brazil.P27. Does Reduction in Gastric Acid Secretion Increase the Daily Energy Expenditure?
J. Melissas, E. Kampitakis, G. Schoretsanitis, E. Kouroumalis. Bariatric Unit, Dept. Surgical Oncology.University Hospital, Heraklion, Crete, Greece.
P28. Gastro-Esophageal Reflux Disease in Obese Patients: Modifications Induced by Bariatric Surgery.
Joaquin Ortega, Carlos Sala, Maria Escudero, Francisco Mora, Adolfo Benages, Vicente Sanchiz, Jose
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Martinez-Valls, Salvador Lledo. Morbid Obesity and Endocrine Surgery Unit, Clinic Hospital and University
of Valencia, Valencia, Spain.P29. Anastomotic Complications after Roux-en-Y Gastric By-pass for Morbid Obesity: A Safe Procedure.
Joaquin Ortega, Carlos Sala, Jose Martinez-Valls, Salvador Lledo. Morbid Obesity and Endocrine Surgery Unit, Clinic Hospital and University of Valencia, Valencia, Spain.
P30. Psychosocial Outcome of LASGB Operations in Adolescents.
T. Pachinger, F. Schmoeller*. Private practice for clinical psychology, Elisabethinen Hospital Linz, Department of Surgery*,Austria.
P31. Impact of Minimally Invasive Surgical Fellowship on Early Outcomes in Laparoscopic Bariatric Surgery
Christine J. Ren, MD*, Marina Kurian, MD†, Mitchell Roslin, MD†, Emma Patterson, MD‡. NYU School of Medicine, New York, NY*; Lenox Hill Hospital, New York, NY†; Legacy Health Systems, Portland OR‡, U.S.A.
P32. Use of BAROS Score System in Patients Operated on for Mobid Obesity: Results of our series.
Carlos Sala, Joaquin Ortega, Fernando López, Stephanie García, Jose Martinez-Valls, Salvador Lledo.Morbid Obesity and Endocrine Surgery Unit, Clinic Hospital and University of Valencia, Valencia, Spain.
P33. The Learning Curve in Bariatric Surgery: Implications in Morbidity and Costs.
Carlos Sala, Joaquin Ortega, Jose Martinez-Valls, Salvador Lledo. Morbid Obesity and Endocrine Surgery
Unit, Clinic Hospital and University of Valencia, Valencia, Spain.P34. Duodeno-Gastric Bile Reflux after Roux-en-Y Gastric Bypass.
Magnus Sundbom, Sven Gustavsson. University Hospital, Uppsala, Sweden.
P35. Bariatric Analysis and Reporting Outcome System following Laparoscopic Adjustable Gastric Banding in Finland.
Mikael Victorzon, Pekka Tolonen. Department of Surgery, Vasa Central Hospital, Vasa, Finland.P36. Remifentanil Anesthesia can Reduce the Consumption Perioperative Intravenous Morphine in
Biliopancreatic Surgery in Morbid Obesity.M. A. Villanueva, F. J. Barredo, A. Muñecas, S. G. Santos, A. Dominguez, C. F. Escalante. S Anestesiología
y Reanimación Hosp Univ Marqués de Valdecilla, Santander, Cantabria, Spain.
P37. Comparison of Respiratory Function Tests after Two Different Anesthetic Techniques following Laparoscopic Morbid Obesity Surgery.
Ziya Salihoglu*, Kagan Zengin**, Sener Demiroluk, Oktay Demirkiran*, Yildiz Kose*, Mustafa Taskin**.University of Istanbul, Medical Faculty of Cerrahpasa, Department of Anesthesiology* and General
Surgery**, Istanbul, Turkey.P38. Conversion of Failed Vertical Banded Gastroplasty (VBG) to Open Adjustable Silicone Gastric
Banding (ASGB).
Mustafa Taskin*, Kagan Zengin*, Ethem Unal*, Ziya Salihoglu**. University of Istanbul, Medical Faculty of Cerrahpasa, Department of General Surgery * and Anesthesiology **, Istanbul, Turkey.
P39. Band Erosions following Adjustable Silicone Gastric Banding (ASGB) for Morbid Obesity.
Mustafa Taskin*, Kagan Zengin*, Ethem Unal*, Ziya Salihoglu**. University of Istanbul, Medical Faculty of
Cerrahpasa, Department of General Surgery* and Anesthesiology**, Istanbul, Turkey.P40. Effect of Position Changes and Pneumoperitoneum on Respiratory Mechanics in Laparoscopic
Morbid Obesity Surgery.
Ziya Salihoglu*, Kagan Zengin**, Sener Demiroluk*, Serpil Cakmakkaya*, Yildiz Kose*, Mustafa Taskin** University of Istanbul, Medical Faculty of Cerrahpasa, Department of Anesthesiology* and General
Surgery**, Istanbul, Turkey.P41. Learning Curve of the Surgical Treatment of Morbid Obesity.
A. Bozbora*, Y. Erbil *, S. Ozarmagan*, U. Barbaros*, N. Ozbey**, Y. Orhan**. *Department Of General Surgery, Istanbul Medical Faculty, Istanbul **Department of Internal Medicine, Istanbul Medical
Faculty, Istanbul, Turkey.
P42. Reoperations after Laparoscopic Adjustable Silicone Gastric Banding (Lap-Band®).
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U. Elmore, A. Restuccia, N. Perrotta, D. Polito*, E. Bianchi**, N. Lo Martire**, G. Silecchia, N. Basso.
Dipartimento di chirurgia “Paride Stefanini”- Policlinico “Umberto I” Università “La Sapienza” Roma”, *ASL Roma G, **ASL Frosinone Presidio Sora, Italy.
P43. Bioenterics Intragastric Balloon; A Non-Aggressive Solution for the Treatment of Obesity?J. Herve; C. H. Wahlen; B. Bastens; B. Dallemagne; C. Jehaes; J. L. Jourdan; S. Markiewicz; J. Weerts. Les
Cliniques Saint Joseph, Liege, Belgium.
P44. Short-term Body Composition Changes Following Laparoscopic Adjustable Silicone Gastric Banding.
A. Diez-Caballero, J. Gómez-Abrosi, I. Monreal, J. Salvador, J. A. Cienfuegos, G. Frühbeck. Depts. of Surgery, Endocrinology and Biochemistry, Clínica Universitaria de Navarra, Metabolic Research
Laboratory, University of Navarra, Pamplona, Spain.P45. Laparoscopic Gastric Bypass for Morbid Obesity: First Experience with 15 Cases.
M. Weber1, M. K. Müller1, F. Horber2, L. Krähenbühl, R. S. Hauser3. 1University Hospital Zürich, Clinic for
Visceral Surgery, Zürich; 2Klinik Hirslanden; 3Consultant for Nutrition, Zürich, Switzerland.P46. Esophageal Dilatation following Laparoscopic Adjustable Silicone Gastric Banding.
Dorothy R. Ferraro, MS, CS, ANP, Richard B. Rubenstein, Stuart Katz. Private Practice, Caremax Wellness and Weight Management Center, E. Patchogue, NY, U.S.A.
P47. Laparoscopic Gastric Banding: The Long Island Experience.Dorothy R. Ferraro, MS, CS, ANP, Richard B. Rubenstein. Private Practice, Caremax Wellness and Weight
Management Center, E. Patchogue, NY, U.S.A.
P48. Dissociation of Plasma Leptin Concentrations with Insulin and Body Fat 24 hours after Laparoscopic Adjustable Gastric Banding.
G. Frühbeck, A. Diez-Caballero, J. Gómez-Abrosi, I. Monreal, J. Salvador, J. A. Cienfuegos. Depts. of Endocrinology, Surgery and Biochemistry, Clínica Universitaria de Navarra, Metabolic Research
Laboratory, University of Navarra, Pamplona, Spain.P49. Unilateral Lower Extremity Compartment Syndrome following a Laparoscopic Roux-en-Y Gastric
Bypass: a Case Report.
Piotr J. Gorecki; Daniel Cottam; L. D. George Angus; Ralph Ger; Gerald W Shaftan. Nassau University Medical Center, East Meadow, NY, U.S.A.
P50. Management and Therapy of Postoperative Complications after Gastric Banding for Morbid Obesity.
U. Winterberg, D. Wagner, H. Bockhorn. Chirurgische Klinik Krankenhaus Nordwest, Frankfurt am Main, Germany.
P51. Laparoscopic Roux-en-Y Gastric Bypass with Silastic Ring (Capella’s Procedure) in the Treatment
of Morbid Obesity: Early Results and Comparison to Technique without Silastic Ring.Thomas Szego, Arthur B. Garrido Jr, Mitsunori Matsuda, Carlos Jose Lazzarini Mendes, Marcelo Roque de
Oliveira, Alexandre Elias, Luiz Vicente Berti. Private Practice, Albert Einstein and Beneficencia Portuguesa Hospital, Sao Paulo, Brazil.
P52. Management of Biliopancreatic Diversion Complications.Santo Bressani Doldi, G. Micheletto, M. Perrini, E. Mozzi. Cattedra di Chirurgia Generale dell’Universita
degli Studi di Milano, Istituto Clinico Sant’Ambrogio, Centro per la Farmacoterapia delle Malattie Nutrizionali
e Metaboliche “E. Genovese e R. Klinger”, Milan, Italy.P53. Preliminary Study of a Single Institution’s Experience with 1,410 Cases of Adjustable Gastric
Banding Performed from July 1995 to April 2001 (5-year Retrospective).Jean-Marie Zimmermann, Michel Blanc, Pierre Mashoyan, Erick Zimmermann, Jean-Marc Grimaldi.
Clairval Private Hospital, Marseille, France.P54. Bariatric Surgery Complications with Adjustable Laparoscopic Gastric Band System (Lap-Band):
Prevention and Treatment.
Carlos Alberto Casalnuovo, Ezequiel Ochoa de Eguileor, Gustave Parrilla, Eduardo Liljesthrom. Hospital de
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Clinicas, University of Buenos Aires, and Private Practice (CCO-Centro de Cirugia de la Obesidad), Buenos Aires, Argentina.
P55. Changed Eating Behavior Produced by Chronic Bilateral Vagus Nerve Stimulation.M. S. Roslin, R. Reddy*, S. M. Parnis**, B. T. Barrett**. Lenox Hill Hospital, New York, NY, *Maimonides
Medical Center, Brooklyn, NY, **Cyberonics, Inc, Houston, TX, U. S. A. .P56. Comparison of Different Techniques of Laparoscopic Placement of Adjustable Gastric Bands.
R. Weiner, D. Wagner, R. Blanco-Engert. MIC-Zentrum Frankfurt-Sachsenhausen, Frankfurt a.M., Germany.
P57. Minimally Invasive Reinterventions to Treat Complications after Bariatric Surgery.F. Aigner, H. Weiss, H. Nehoda, H. Bonatti. Univ. Hospital of Surgery, Dep. of Gen. Surg., Innsbruck, Austria.
P58. Incidence of Smoking and Weight Loss in our Bariatric Population.Joseph F. Capella, Rafael F. Capella. Hackensack University Medical Center, Hackensack, NJ, U.S.A.
P59. Solid State Barium Meal in Lap-Bands Inserted with Pars Flaccida Technique.
Marina S. Kurian, Mitchell S. Roslin. Department of Surgery, Lenox Hill Hospital, New York, NY, U.S.AP60. The Influence of Gastric Banding on Plasma-Aminoxidase (PAO) - a Possible Prognostic Factor in
Obesity-Associated Morbidity.J. Klocker, B. Labeck, H. Nehoda, F. Aigner, A. Klingler, C. Ebenbichler, B. Föger, M. Lechleitner, H.Schwelberger, H. Weiss. Departments of General Surgery and Internal Medicine, University Hospital
Innsbruck, Austria.P61. Our Changing Approach to the Prophylaxis of Venous Thromboembolism in Bariatric Surgery.
Maria Laura Cossu, Enrico Fais, Matteo Ruggiu, Claudio Sparta’, Franca Cossu, Giuseppe Noya.Department of Emergency Surgery, University of Sassari, Italy.
P62. Hemodynamic and Cardiac Functional Improvements after SurgicalTreatment of Severe Obesity.
F. Mittempergher, D. Moneghini, B. Salerni, S. Nodari*, A. Madureri*, L. Dei Cas*. Chair of General Surgery and *Chair of Cardiology, University of Brescia, Italy.
P63. Laparoscopic Gastric Banding in the Elderly.H. Nehoda, K. Hourmont, T. Sauper, R. Mittermair, M. Lanthaler, F. Aigner, H. Weiss. Department of General Surgery, University Hospital of Innsbruck, Austria.
P64. Routine Cholecystectomy Concomitant with Bariatric Surgery. Is it Needed?Spiros Papavramidis, Konstantinos Sapalidis, Nikolaos Deligiannidis, Ilias Papavasiliou, Orestis Gamvros.
3rd Surg. Dept. AHEPA Hosp. Aristotelian University of Thessaloniki, Greece.P65. Improvement in Metabolic Co-Morbidities following Weight Loss from Gastric Bypass Surgery.
Richard S. Stubbs. Wakefield Gastroenterology Centre, Wellington, New Zealand.
P66. Normal Body Weight: Is there a Realistic Chance after Bariatric Surgery?B. Husemann, Th. Sonnenberg. Dominikus-Krankenhaus, Dusseldorf, Germany.
P67. Patient Characteristics Influencing Weight loss following LASGB-Operation.
Ralph Peterli, Yael Anner, Peter Tondelli. Surgical Clinic, St.Claraspital, Basel, Switzerland.P68. Postoperative Thromboembolic Complications after Obesity Surgery.
A. Westling, S. Gustavsson Assoc Prof. Department of Surgery, University Hospital Uppsala, Sweden.P69. Laparoscopic Biliopancreatic Diversion without Gastrectomy.
P70. Quality of Life is Improving after Lap-Band Gastric Banding for Morbid Obesity.Beda Saida, Jean-Marc Chevallier, Frank Zinzindohoue, Richard douard, Jean-Louis Berta, Jean-jacques
Altman, Paul-Henri Cugnenc. Departments of Surgery and Nutrition. Hôpital Européen Georges Pompidou, Paris, France.
P71. Our Bariatric Surgery Experience with Adjustable Gastric Banding.
S. B. Doldi, G. Micheletto, M. Perrini, E. Lattuada, M. A. Zappa, M. Fioravanti. Cattedra di Chirurgia Generale dell’ Università degli Studi di Milano - Istituto Clinico Sant’Ambrogio, Centro per la Farcomacoterapia delle
Malattie Nutrizionali e Metaboliche E. Genovese R. Klinger. Milan, Italy.
1. OBESITY SURGERY: UTILITY OF PSYCHOLOGICALAREA IN MULTIDISCIPLINARY TEAM AND FUTURE CHAL-LENGES.Susana Bayardo, Silvio Albarracín, Antonio Cascardo, AnaCappelletti, Hernán Franco, Adrián Alvarez. IMETCO (InstitutoMultidisciplinario Especializado en el Tratamiento y Cirugía dela Obesidad)
Background: Scientific research have proved remarkableachievements in reducing and keeping weight losing in operatedpatients with adjustable gastric banding, as well as theirimprovements in quality of life. Control and follow up allows toobserve the success of procedure related to the grade of com-pliance to treatment.
Psychologic evaluation allows to know motivational aspects,personality features, psichopatological antecedents, pre andpost-surgery fears, psichosocial support and continence.Informed consentiment shows that the patient knows andaccepts to follow requirements. However, difficulties with com-pliance are frequently observed along the process.We are inter-ested in studying difficulties related to compliance, as it mayfrustrate initial expectations of patients when asking and accept-ing surgery.
Methods: Self filled questionnaires were used as well as psy-chological pre and post surgery interviews in 100 patients whounderwent adjustable gastric banding surgery at IMETCO(Instituto Interdisciplinario Especializado en el Tratamiento yCirugía de la Obesidad) during the period 8/98 - 2000, with atleast, one year post-surgery follow up.Results of evaluation were checked with weith losing, atten-dance to medical interviews, and re-operations due to band dis-placement.
Results: Information from research, allows us to inform staffabout patient characteristics, which may interfere in adaptatinand compliance pre and post surgery. Results were concordantto international statistics, in relation to percentages of weigh los-ing. In patiens which results were not the expected because oflack or poor compliance to the treatment, we have identified psi-chosocial factors which took part.
Conclusion: Nowadays, psychology gives multidisciplinaryteams major instruments for treatment. Challenge consists onimproving some of them, regarding validity and reliability indetecting predicting factors, which are useful to get compliancerelated to surgery itself and post surgery treatment, as well asto define characteristics for the kind of surgery which does notdepend on a conduct change.
2. CONTINUING EDUCATION, OUR RESPONSIBILITY TOTEACH LESSONS OF THE BODY, BONES AND BRAINS.Jacquelyn K. Smiertka, RN. Bloomfield Bariatrics-PrivatePractice, Michigan, USA
Our patients come to us for help. Obesity surgery, known tobe the most viable treatment for this deadly disease, appears tobe the only answer for millions of individuals all over the world.Our most important responsibility following the preoperativeeducational process and safe surgery is the process of continu-ing education. This paper will cover topics that will focus onsome of the lessons we can teach regarding the bones, thebody and the brains.
For those who do malabsorption procedures, materials willbe provided for lessons that can be taught to lay individuals
regarding preventative and treatment measures of osteoporo-sis.
The body lessons include how to visually educate the layper-son to be able to understand the anatomy and how their surgerywill work for them. There will also be a discussion along witheducational material regarding what it means to have variousmedical problems related to obesity, such as hypertension, dia-betes, sleep apnea as well as what exercise can do for the body.
Discussion that involves the “brain” is inclusive of the neces-sity of having support groups as well as utilizing the services ofpsychologists, psychiatrists and therapists.The focus will be onthe importance of psychological follow-up that should be madeavailable to the individuals who have had weight loss surgery.
3. THE “INFO G” GROUP: A SUPPORT TEAM FOR THEOBESE PATIENT.Christian A.G. Thyse RN. Centre Hospitalier Régional de Huy,Huy, BelgiumAt the begining of gastroplasty in our hospital, it was very diffi-cult to take care of the obese patient because of their psycho-logical profile.To help the staff and the patient, we have decidedto have a meeting with the surgery staff and the allied healthstaff. The proposed solution was the « INFO G » group(Information and gastroplasty). This group is composed by aDietician, a Psychologist and a Nurse. After the first contact withthe surgeon, the patient have to have an appointement with thegroup.
During a discussion with the patient, the psychologist and thedietician try to describe his psychological and eating profile.Thenurse is present to answer question about the nursing and thecare. Secondly, the patient come back with a repport of the thegroup, so that, the surgeon has a complete history of his patientand can propose (or not) a surgical solution. If necessary, it isproposed to the patient to be followed by a psychological teamor a dietician before of after surgery. The role of the group is togive all the information needed by the patient about his futureway of live and his future eating attitude. It is also easyer to pre-vent and detect the failure risk.
Conclusion: We have began this multidisciplinary approch 15years ago and today we are sure that it can help the patient butalso all the team for the obese patient management.
4. PRELIMINARY SURVEY OF SEXUAL ORIENTATIONAFTER WEIGHT LOSS SURGERY IN HOMOSEXUALFEMALES.Delphine Nuglozeh-Buck, RN, Barbara Metcalf, RN, WilliamHarman, Ph.D., Gregg H. Jossart, MD, Robert A. Rabkin, MDPacific Laparoscopy, San Francisco, CA, USA
Background: A subset of morbidly obese female patients whowere self-identified as homosexual before weight loss surgerywas obtained from a large surgical bariatric practice.
Methods: In conjunction with routine post-operative follow-upafter surgery for mobid obesity, changes in sexual orientationwere recorded. These changes were self-reported.
Results: Changes in patients’ sexual orientation occurred in asignificant minority of bariatric surgical patients.
Conclusion: Transition to heterosexual orientation does occurafter bariatric surgery. Future research may be helpful in guid-ing patients through often difficult periods in the recoveryprocess.
Allied Health Program
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5. PREGNANCY AFTER GASTRIC BYPASS.Bobbie Lou Tripp, RN, Melvin S. Swanson, PhD, PaulCunningham, MD, Walter Pories, MD, Sharon Shipley, RN, BretBrown, RHIA, Kenneth MacDonald, MD. Brody School ofMedicine, East Carolina University, Greenville, NC, USA
Background: It is known that obese women who becomepregnant are at higher risk for developing obstetric complica-tions and they have a significant incidence of infertility.The pur-pose of this study is to evaluate outcomes of patients whobecame pregnant after a Roux-en-Y gastric bypass.
Methods: Between January 1980 and June 2000, 60 patientsbecame pregnant after having a Roux-en-Y gastric bypass.During November 2000, a phone survey located 34 of them andthey were asked a series of questions about their post-surgerypregnancy history, pregnancy complications, weight gain duringpregnancy, and baby’s birth history.
Results: Of the 34 patients, 21 (62%) were Caucasian and13(38%) were African American. The average preoperativeweight for these patients was 142kg (ranging from 104 to247kg), with a mean BMI of 53. Twenty of the patients reportedattempts to get pregnant before surgery and 14 (70%) of thesehad difficulty conceiving before surgery. The average time toconceive after surgery was 38 months, ranging from 6 monthsto 9 years.The average age at birth was 33 years, ranging from23 to 41 years. Mean weight gain during pregnancy was 10kg,with 4 patients either losing or not gaining weight. Twenty one(62%) were able to return to their pre-pregnancy weight. Themean percent of excess weight loss for these patients was 46%,with an average follow-up of 13 years. Before the pregnancy, 7(21%) reported health problems, 19 (56%) reported problems orcomplications during pregnancy, while 8 (24%) reported prob-lems after the birth. Six (18%) reported diabetes complicationsduring pregnancy, while another seven had hypertension. Nine(26%) of the patients, 6 Caucasians and 3 African Americans,gave birth prematurely, while 6 (18%) had one or more miscar-riages. Six (18%) of the patients reported health problems withtheir baby.
Conclusion: For those women trying to conceive beforesurgery, 70% reported difficulty in conceiving. Over halfreported health problems during the pregnancy, with the prob-lems ranging from minor complaints of edema to more seriouscomplications of gestational diabetes and hypertension. Therate of prematurity was 23% for the black women and 29% forthe white women, far exceeding the United States rates ofapproximately 13% for nonwhite newborns and 7% for whiteinfants. In addition to prematurity, infant health problemsincluded jaundice, respiratory distress syndrome, deafness,asthma, aspiration pneumonia, and autism.
6. PRE AND POSTOPERATIVE PROTOCOL FOR BARIATRICSURGICAL PATIENTS.Loukidi Aggeliki, Mead Nancy, and Kalfarentzos Fotis. NutritionSupport and Morbid Obesity Clinic, Surgical Department,University Hospital of Patras.
Background: Patients undergoing surgery for morbid obesityneed special attention and education both before and aftersurgery in order to ensure the best possible outcome.
Methods: At our institution all patients undergoing bariatricsurgery follow a specific pre and postoperative protocol super-vised and run by the Morbid Obesity team including surgeon,nutritionist and nurse. Preoperatively, patients are first fullyinformed by the surgeon regarding the advantages and disad-vantages of the surgical option and what exactly is involved. For
this purpose, each patient is also given a detailed bookletdescribing what they have just heard described by the surgeon.If a patient then decides to proceed with the surgery, he or sheenters the pre-surgical program of our morbid obesity clinic,which lasts 2-3 weeks and includes a complete physical exam-ination, blood chemistry workup, nutrition evaluation and edu-cation, ultrasound of the hepatobiliary system, cardiology,endocrinology, pulmonary, and psychiatric evaluations andother medical evaluations when necessary. Nursing protocolimmediately before and after surgery includes standard patientpreparation and care and administration of prescribed medica-tions. Immediately following surgery, the patient stays in therecovery room until stable and alert and is then transferred tothe surgical ward providing no complications occur requiringcare in the ICU. The patient is mobilized as early as possible,usually on the same day. On the 4th postoperative day a radiol-ogy examination is performed to check for any leaks and follow-ing this, the patient begins postoperative per os feeding and isfollowed by the nutritionist.Most patients are discharged on the6th or 7th postoperative day with full medical and nutritionalguidelines and return on the 20th day for removal of the staplesand further discussion with the nutritionist. Finally, the patiententers the regular postoperative follow-up program with visits tothe outpatient clinic for evaluation at 1, 3, 6, and 12, 18 (BPDwith RYGBP pts) and 24 months following surgery and yearlythereafter.
Results: From June 1994 to April 2001, 196 patients under-went various bariatric surgical procedures at our institution. Allpatients followed the specific pre- and postoperative protocoldesigned by our Clinic and no patients have been lost to follow-up. The program is low in cost and relatively easily carried out,and it is our opinion that this program has helped our patients tobetter understand their surgery, to return for scheduled follow-up visits, to reduce the incidence of long-term complicationsand to have the best possible overall outcome.
Conclusion: Having a specific pre- and postoperative patientprotocol with an organized team approach is essential for theimmediate and long-term success of bariatric surgical patients.
7. DIETARY MANAGEMENT OF PATIENTS WITH MORBIDOBESITY AFTER VERTICAL BANDED GASTROPLASTY.Vassiliki Komessidou, A. Papakonstantinou, P. Alfaras, I. Terzis,P. Moustafellos, S. Gourgiotis, S. Brousta, E. Hadjiyannakis.Department of Nutrition and 1st Department of Surgery«Evangelismos» General Hospital, Athens, Greece
Background: Morbid obesity (MO) is a serious conditionrequiring surgical treatment. The post-surgical diet of thesepatients is a necessary supplement of their surgical manage-ment.
Methods: To evaluate the importance of post-surgical dietarymanagement, 290 patients with MO (64 males and 226females), age 17-56 years, body weight 107-217 kg, were put ina special liquid diet (SLD) after vertical banded gastroplasty(VBG). Daily intake was 655 kcals: 61.4g protein, 91.2g carbo-hydrates, 4.9g fat, and vitamins and minerals based on normaldaily requirements.The total quantity of the liquid was 250 ml,which was dissolved into 5 meals of 50ml each.The ingestion ofonly 50 ml/meal was necessary due to the small volume of thegastric pouch.
Results: The patients lost 13-28kg and 35-56kg at 1 and 3months, respectively. After 3 months, patients were graduallyput on a regular diet. Ninety (90) patients (21 males and 69females) reached their ideal body weight within 12 months,
while 129 patients (30 males and 99 females) had lost over the50% of their overweight and were approached their ideal bodyweight at the end of the first postoperative year. Plasma choles-terol (244 ± 42 mg/dl), triglycerides levels (171 ± 33 mg/dl),VLDL levels (19.32 + 1 mg/dl) were reduced at the end of firstpostoperative year. (182 + 2 mg/dl, 119 + 72 mg/dl and 17.11 +1,56 mg/dl, respectively p<0.05). HDL levels (22.13 + 1.23mg/dl) were increased (24.22 + 1.16 mg/dl) in the same period.
Conclusion: Special liquid diets for the first postoperativeperiod after VBG contribute significantly to rapid weight loss andreduction of plasma cholesterol, triglyceride and VLDL levels inpatients with morbid obesity.
8. COPING STYLE AND EATING PATTERN IN OBESE ANDMORBIDLY OBESE PATIENTS WHO WERE SCREENEDPREOPERATIVELY FOR A GASTRIC RESTRICTION PRO-CEDURE.Rogier Hörchner MSc, RN, Wim Tuinebreijer, MD, Ph.D, MSe.Department of Clinical Research Ra-Medic & Dutch ObesityClinic Hilversum, The Netherlands
Background: Morbid obesity can be seen as a chronic dis-ease. Stress can indirectly affect illness by altering a person’sbehaviour patterns like health behaviours. A restrictive bariatricintervention may lead to achieve a permanent modification ofthe eating habits of morbid obese patients.These bariatric inter-vention can be seen as a stressful event. To analyse the rela-tionship between eating pattern and coping style of (morbid)obese patients, the Utrechtse Coping List and Dutch EatingBehaviour Questionnaire were used in this study.
Methods: The present study was set up to analyse the rela-tionship between eating pattern and coping style of (morbid)obese patients who consider a restrictive bariatric procedure.Coping style was monitored by using the Utrechtse Coping List.Eating pattern was monitored by using the Dutch EatingBehaviour Questionnaire in 100 (morbid) obese patients.
9. ANESTHETIC CARE IN MORBID OBESITY.Adrian Alvarez; Antonio Cascardo, Albarracin, Silvio. IMETCO(Multidisciplinary Institute Specialized in the Treatment and theSurgery of Obesity), Buenos Aires, Argentina
Morbid obese patients present several anatomic and physilogical impairments. This situations are responsable of theincreasing risk of transoperatoty complications.Anaesthesiologistand surgeons must know about them in orderto prevent their appearence.
In this video are shown the principal actions that we havetaken (after four years of experience) to improve the patientssecurity.
Positioning, monitoring, drugs delivery devices, intubationdevices, and postoperative analgesia devices appears, all reg-istered during different procedures.Incidence of different types of complications are included in atable.
10. BARIATRIC OPERATION IN A PATIENT WITH POSSI-BLE PSYCHIATRIC CONTRAINDICATION-CASE REPORT.Azevedo AP,Libanori HT,Segal A. Institute of Psychiatry-Hospital das Clinicas-Sao Paolo University Medical School
Grade III obesity is considered a chronic disease with pooroutcome when treated by conservative approach. The moreconsistent results tend to be obtained through surgical proce-dures.
The indications and contra-indications of obesity operations
are still not completely clarified, specially on the psychiatricfield. Some psychiatric disorders are currently considered con-traindicative for these procedures, mainly affective, psychoticand personality disorders.
The authors describe the case of a 37 years old female sub-ject, obese since the age of 12 presenting appetite-suppressantdrug abuse and dependence since the age of 15.She had a diagnosis of Bulimia nervosa and BorderlinePersonality Disorder (DSM IVTM).That patient was submitted toa gastric-bypass operation on August 2000 with BMI 40.2.Thepresent BMI is 27.2 and the patient is free of the previous psy-chiatric symptoms, with adequate response to the regular treat-ment.
The authors conclude that selected psychiatric morbidlyobese patients may be successfully treated by standardBariatric operations. Psychiatric follow up is mandatory.
11. ADDICTIONS? ROLE AFTER BARIATRIC SURGERY.Elisabeth Ardelt-Gattinger, Irene Hofmann, Edda Angermann &Melodie Moorehead. Psychological Institute of University ofSalzburg, Austria Holy Cross Hospital Ft.Lauderdale, USA
Background: Theories about addictions role in obesity arecurrently in conflict (Ellis et al 1992, Pudel & Westenhöfer 1998).Its role is not a purely academic matter, since questions aboutits role affect decisions on intervention and therapy before andafter bariatric surgery. In first studies we could prove that 100%of subjects with a BMI > 40 meet the minimum of three criteriaof dependency described in DSM IV. Additionally, we found thatsubjects with a BMI > 40 do not differ significantly from alco-holics and smokers in the factors of our addiction questionnaire.The question arises, how addiction changes after surgical inter-vention, when abnormal food intake is stopped.
Method: To test whether or not obese people with a BMI > 40continue to have addictive structures we tested 254 people (195female / 59 male) before (97/33) and after surgery (98/26). Thesamples were tested with our Addiction scale, the Moorehad-Ardelt Quality of Life Questionnaire, and a self-esteem scale.
Results: Results show, that quality of life-, self esteem-, andaddiction-scores differ significantly between people before andafter surgery.The first 2 scales correlate significantly with weightloss after surgery. The addiction score does not correlate withweight loss. BUT when we compared two groups of subjects (alot/little weight loss), we found significant differences concerningthe addiction scale.
Conclusion: For the psychological screenings before surgeryit is of immense importance to take the addiction factor into con-sideration.Additionally, it is necessary for the time after surgery(the critical phase being 6 months after the intervention) to pro-vide psychotherapy for highly addicted persons who do not loseenough weight
12. A 15-YEAR EVALUATION OF BPD RESULTS ACCORD-ING TO BAROS CRITERIA.Giuseppe M. Marinari, Giovanni Camerini, Federica Murelli,Francesco Papadia, Paola Marini, Cesare Stabilini, FlaviaCarlini, Nicola Scopinaro. DICMI, Semeiotica Chirurgica R,University of Genoa School of Medicine, Genoa, Italy
BPD is considered the most effective bariatric procedure.Nevertheless, even if several studies show a very good weightloss (WL) and maintenance, and a consequent improvement inmedical conditions, the expected amelioration in quality of life(QoL) was never reported. BAROS, which takes into considera-tion WL, comorbidities, complications, reoperations, and QoL,
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has proven to be a standard reference in the outcome evalua-tion in bariatric surgery. So as to apply BAROS to BPD subjects(s.), we sent out a questionnaire to 1800 AHS BPD s. which hadbeen operated on between 1984 and 1998. It was returned andfilled out correctly by 820 of them (46%); in 91 cases (5%) theletters were returned unopened and in 27 cases (1.5%) thequestionnaire was incomplete and could not be used. Out of the820s, 594 were women. Mean preoperative age was 38±11,mean body weight 128 kg ± 26, corresponding to a mean per-centage in excess weight of 118 ± 38. The WL, which isexpressed as percent loss of the initial excess weight (IEW%L),both in the unrevised and revised patients, was 69 ± 15 at 14years (60 cases), 66 ± 18 at 12 years (131 cases), 68 ± 18 at10 years (334 cases), 69 ± 18 at 8 years (532 cases), 68 ± 18at 6 years (659 cases), 67 ± 18 at 4 years (738 cases), and 68± 18 at 2 years (800 cases).The mean score attributable to WLwas 2.2 ± 0.7. Dyslipidemia (376 subjects, 46%), sleep apnea(36 subjects, 4%), obesity hypoventilation syndrome (62 sub-jects, 8%) and type II diabetes (118 subjects, 14%) were allresolved, whilst hypertension, present in 432 s, disappeared in376 (87%), was improved in 38 (9%) and was unchanged in 18(4%). Obesity-related comorbidities were absent in 45 s.only.Revisions were 52 (6.3%), which were mainly due to recurrentprotein malnutrition. The mean score referred to an improve-ment in medical conditions, from which complications and reop-erations were deducted, was 2.0 ± 1.1. The mean scoreobtained by the Quality of Life Questionnaire was 1.0 ± 1.5, andthe mean total score was 5.1 ± 2.2, which is defined as a verygood result by the scoring key.Out of the 820 s., 30 (3.7%) wereclassified as a failure, 99 (12.1%) were fair results, 219 (26.7%)good results, 306 (37.3%) very good results, and 166 (20.2%)excellent results.We divided the 820 s. into two groups: the firstgroup consisting of 573 before the adaptation of the alimentarylimb to patient’s characteristics, and the second group consist-ing of 247 submitted to the ad hoc stomach ad hoc alimentarylimb (AHS AHAL) BPD. The revision rate was 8.6% in the firstgroup and 1.2% in the second one, while the mean IEW%L was68.6 ± 18 and 64.3 ± 17, respectively; the mean WL score was2.23 ± 0.7 in the first 573 s. and 2.13 ± 0.6 (ns) in the others, themean QoL score was 0.9±1.5 and 1.3 ± 1.3 (p < .001), respec-tively, and the mean total score was 5.0 ± 2.2 and 5.5 ± 2.0 (p=.002). According to the scoring key, we had a 4.5% failure ratein the first group and a 1.6% failure rate in the AHAL group,while 14% and 7.7% of the cases, respectively, were fair results,27.2% and 25.5% good, 34% and 44.9% very good, and 20.2%of both groups excellent results.
Adapting gastric volume and intestinal lengths to the patientcharacteristics has decreased the incidence of metabolic com-plications, thus leading to a sharp fall in the need for surgicalrevision.BAROS evaluation of BPD highlights the importance ofits flexibility: the new policy of tailoring the procedure to individ-ual characteristics caused a drop in the failure rate and anincrease in good, very good and excellent results (90.6% of thetotal). Particularly, the increase in the QoL mean score showsgreater patient satisfaction, despite the lower WL.
13. PREOPERATIVE BEHAVIORAL-COGNITIVE PSY-CHOTHERAPY FOR BARIATRIC SURGERY PATIENTS.Mingardi A, Crozeta G, Larino MA, Libanori HT, Segal A.Institute of Psychiatry-Hospital das Clinicas-Sao PaoloUniversity Medical School
Behavioral-cognitive psychotherapy (BCP) is widely recog-nized as one of the cornerstones on the treatment of obesity.
Considering morbidly obese patients, bariatric surgery is thetreatment of choice.BCP is not effective for this population evenwhen associated to other clinical procedures. In spite of that, itmay have an important role as a preparatory routine, consider-ing the magnitude of behavioral changes caused by these oper-ations.
Fifteen female morbidly obese patients attended group BCPsessions on a weekly basis for 6 moths prior to the operation.Psycho-educational strategies including reports from operatedpatients were used. At the end of the preoperative BCPapproach, the patients were widely informed about the opera-tion itself, risks and consequences.Although further studies are required in order to validate thispoint of view, the cognitive and affective comprehension of thetreatment may be better achieved under this method.
14. PSYCHOLOGICAL FACTORS AND PATIENT MOTIVESIN RELATION TO BMI REDUCTION IN MORBIDLY OBESEPATIENTS FOLLOWING BARIATRIC SURGERY.Vlachos Ioannis O.**, Stergiou Theofilos**, Mead Nancy*, BeratiStavroula**, Kalfarentzos Fotis*. Nutrition Support and MorbidObesity Clinic, Surgical Department*, and PsychiatricDepartment** University Hospital of Patras, Greece.
Background: Psychological factors and patient motives mayaffect the overall outcome of surgery in morbidly obese bariatricpatients.
Methods: From June 1994 to April 2001, 196 morbidly obesepatients underwent various bariatric procedures at our institu-tion. All patients were assessed psychiatrically before the oper-ation by the same psychiatrist (I.O.V.). In addition, they com-pleted the General Health Questionnaire-28 and the EysenckPersonality Questionnaire (EPQ). Finally, they answered a semi-structured questionnaire aimed at showing what their mainmotives were for deciding to have a bariatric operation in orderto lose weight.
Results: The results presented here refer to the first 92patients undergoing surgery. Personality traits, as described inthe EPQ, did not correlate with the reduction of BMI, whilepatients psychiatric caseness, as determined by the GHQscore, was associated with the most marked reduction in BMIafter the first and the second year of follow-up. The strongestmotive for wanting to lose weight was, for men the diminishedability to perform their daily activities and for women the bodyimage disparagement.Younger patients tended to state dissat-isfaction with their weight and shape as their primary motive forsurgery, while elderly people were more concerned with healthproblems.
Conclusion: Psychological status and patient motives seemto play a part in the BMI reduction after bariatric surgery, whilepersonality does not. Women and younger people have differentmotives for undergoing bariatric surgery than men and olderpatients.
15. THE EFFECTS OF GASTRIC BYPASS SURGERY ONMEASURES OF PSYCHOLOGICAL DISTRESS.Mary Gallacher, M.B., Ch.B., Cynthia Buffington, Ph.D., andGeorge S.M. Cowan, Jr., M.D. The University of TennesseeHealth Science Center, Department of Surgery and The ClinicalResearch Center, Memphis Tennessee, U.S.A.
Background: Our previous studies found a high degree ofdepression and anxiety among morbidly obese (MO) bariatricsurgical candidates. The purpose of this study was to examinethe influence of weight loss following gastric bypass (GBP)
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surgery on these measures of psychological distress.Methods: The study population included 99 MO GBP surgical
candidates, mean weight = 135 ± 2.9 kg (range = 90-212.9 kg),mean BMI = 50.5±1.1 (36.2-80.7), waist circumference = 47.1 ±0.7 cm (34-66 cm) and average age = 41 ± 1.1 yrs (range = 21-73 yrs). Depression and anxiety were measured by the BeckDepression and Anxiety Inventories (BDI and BAI, respectively)before surgery and at postoperative (post-op) periods 1-3, 6-9,12, and ³ 24 months.
Results: Prior to GBP, 80% of the MO population were clini-cally depressed and 61% had high anxiety. Pre-op BDI and BAIscores were highly correlated (r=0.69, p<0.0001) but neither ofthese measures of psychological distress were significant(p>0.05) correlates of body weight or other anthropometrics.
Following GBP, total body weight declined from an average of135 kg pre-op to 113, 92, 80, and 75 kg at post-op months 1-3,6-9, 12, and ³ 24, respectively. BDI scores fell by 58% within thefirst 1 to 3 post-op months (19.8 to 8.3) and did not significantlychange thereafter. BAI scores declined by 54% during the first 6to 9 post-op months (13.8 to 6.3) but returned toward pre-op val-ues by the ³ 24 month observation period. Post-op changes inanxiety or depression following GBP were not significantly(>0.05) correlated to changes in body weight or other anthropo-metrics.
Conclusions: GBP transiently improves levels of anxietyamong MO patients and has a sustained salutary influence ondepression.
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3rd International Symposium on LaparoscopicObesity Surgery (ISLOS)
16. LAP BAND, CHANGES IN SURGICAL TECHNIQUE:OUTCOME OF 1410 SURGERIES PERFORMED FROM JULY1995 THROUGH APRIL 2001.Jean-Marie Zimmermann, Michel Blanc, Pierre Mashoyan, ÉrickZimermann, Jean-Marc Grimaldi. Clairval Private HospitalCenter, Marseille, France
The authors present the changes in their technique for place-ment and fixation of adjustable gastric bands.
From July 1995 through December 1999, 1145 patientsunderwent surgery. The identical technique was used from thestart: laparoscopy, 5 trocars, calibration balloon inflated with 15cc, position in contact with the stomach, band fixed with threesutures through the stomach, above the band. The sutures inthe splenic region were also placed through the left crus of thediaphragm. Therefore, the materials used were the LAGB withthe original technique in 1090 cases and the SAGB in 55 cases.
We felt that the 11% slippage complication (up to 18% in theliterature) was unacceptable.This occurred in the series of 1090LAGB cases. One-hundred twenty-nine cases underwentlaparoscopic reoperation (seven patients had two successiveslippage events).
In addition to a new approach to positioning the prosthesis,all in pars flaccida position (LAGB 10.0cm, 103 cases; LAGB11.0cm, 123 cases; SAGB, 50 cases), a new method of pros-thesis fixation was used.
The idea is to immobilize the region located between theband and the diaphragm. Three sutures are used for this fixa-tion:- Left, fixing the stomach (fundus of the stomach), below theband, to the left crus of the diaphragm- Medial, stomach below the band, stomach above the band- Right, fixing the stomach (lesser curvature of the stomach),below the band, to the right crus of the diaphragm
Thus the region is well closed and the band is fixed, but notblocked. There is no longer any expansion space above thesesutures and the diaphragm, as was the case with the originaltechnique.
Admittedly there has been insufficient follow-up time, butsince January 2000, there has been no slippage in the 278patients who received this type of surgery. During that sameperiod, there were 27 occurrences of slippage with the originaltechnique.
Finally, placement of the band requires only four trocars:
10/12 mm for open laparoscopy and the optics, 10 mm for theliver retractor, 5 mm and 15 mm for dissection and insertion ofthe prosthesis.
In this way, the authors hope to contribute to improving theresults with the laparoscopic gastric banding technique, which,despite its drawbacks, is effective and still remains the leastaggressive and most easily reversible technique for the surgicaltreatment of morbid obesity.
17. PROXIMAL GASTRIC BANDING AFTER FAILED GAS-TRIC RESTRICTIVEOPERATIONS.Eliezer Avinoah, MD, Solly Mizrahi, MD, Leonid Landsberg, MD.Surgery A, Soroka Medical Center, Faculty of Health Sciences,Ben-Gurion University, Beer-Sheva, Israel
Between 1980 to 1985 624 patients had Roux en Y gastricbypass operation. From 1986 vertical gastroplasty was per-formed in 1300 patients. We began to perform open and laparscopic gastric banding for the last four years.46 patients were re-operated after failed gastric restrictivesurgery for morbid obesity.Their mean age was 44±9 years old(34 to 67 years) and their BMI (body mass index) was 41±4.Seven (15%) patients had previous Roux en Y gastric bypassand 39 (85%) patients were after vertical gastroplasty. Thepatients after gastric bypass surgery had enlarged gastroje-junostomy.39 (80%) patients after gastroplasty were reoperatedbecause of stapled line disruption , two(5%) had enlargedbanded stoma, and six (15%) had nutritional restriction intoler-ance. The average time elapsed from the first surgery was 6±7years(3 to17 years). Patients had open or laparoscopic surgeryat which adjustable gastric band was inserted retroperi-tonealy from the angle of Hiss to the lesser curve at the level ofthe caudate lobe of the liver. Mean operative time was 115±25minutes and hospital stay was two days after open surgery andone day after laparoscopic surgery. Two patients had woundinfection and five had postoperative hernia. There was nomortality. a mean of three years after surgery the mean BMI is25±6. We conclude that proximal gastric banding is a safe andeffective operation both for gastric bypass and for vertical gas-troplasty.
18. TECHNICAL MODIFICATION IN LAP-BAND IMPLANTCasalnuovo Carlos Alberto, Ochoa de Eguileor Ezequiel,Parrilla Gustavo, More Marco. Hospital de Clínicas, University
of Buenos Aires, and Private Practice (CCO-Centro de Cirugíade la Obesidad), Buenos Aires, Argentina.
Background: The adjustable Lap-band, requires a simpletechnique, with minimal morbidity.The pouch volume and the stoma diameter, are the two mainfactors that regulate the weight loss.The surgical technique and the procedure have to be optimaland effective.
Methods: After the learning curve (30 operations) we intro-duced some modifications to the technique and the procedure,which are shown on the VIDEO.1 - better dissection of the left crus of the diaphragm and of theleft esophagus-gastric junction.2 - the beginning of the tunnel dissection, is carried out at ahigher level. The stomach is separated from the inferior part ofthe right crus in a subcardial level.The perigastric fat is includedtrying to separate the pneumogastric nerve. The whole dissec-tion is in the phrenogastric ligament thickness.3 - the “gastrostenometer” is not used anymore.4 - a better anterior gastric wall fixation with more sutures overthe band (gastrogastric and gastrodiaphragm).5 - the radiological control with hydrosoluble solution before dis-charge from hospital is used in selective form.
Results: Of the 150 operated on patients, two slippages weredeveloped. One anterior needed relaparoscopy 4 1/2 monthslater, with gastric wall reduction and new fixation.The other one,posterior, in that was used the original perigastric technique inthe primary operation, it was partially corrected with band defla-tion, carrying out a higher and more stable repositioned newband by relaparoscopy 16 months later. No gastric lesions andno mortality. The surgical time is reduced to 75 min (40-120),doing easier the dissection, especially in patient with BMI = />60.
Conclusions: With the modifications was achieved: 1)decrease surgical time, 2) better cost/effectiveness, 3) moresimple dissection in patients with BMI=/>60, 4) create a virtualpouch at the beginning, with a very small size later, 5) obtain ahigher and stable band position, that prevent the posterior slip-page, and also decreases the possibilities of instrumentallesions on the posterior gastric wall. The best fixation with gas-trogastric and to the diaphragm crus sutures contribute to avoidthe anterior slippage, 6) decrease the morbidity, avoiding com-plications.
19. LAP-BAND GASTRIC BANDING IN A PUBLIC UNIVER-SITY HOSPITAL: SUCCESS AND PITFALLS WITH 450PATIENTS IN FOUR YEARS.Jean-Marc Chevallier, Franck Zinzindohoue, Jean-PhilippeBlanche, Richard Douard, Jean Louis Berta, Jean JacquesAltman, Paul-Henri Cugnenc. Departments of Surgery andNutrition. Hôpital Europpéen Georges Pompidou, 20-40 rueLeblanc 75908 PARIS cedex 15, France
Background: Laparoscopic approach is gaining widespreadacceptance as a gastroplasty for morbid obesity. Adjustablegastric banding is a restrictive procedure considered as lessinvasive and potentially reversible , which could guarantee abetter quality of life. In our consecutive series of 450 patients weevaluated prospectively complications and followed ExcessiveWeight Loss (E.W.L.) since four years.
Methods: from 04/1997 to 04/2001, 450 patients have beenlaparoscopically operated on for severe obesity according toN.I.H. criterias : 390 women, 60 men, with a mean age of 40,4years (16 – 66),a mean preoperative weight of 119,7 Kgs (85 –
195) and a mean B.M.I. of 43,9 Kg/m2 (35,1-65,8). 157 patientshad no comorbidity and the 293 remaining had 1,48 comorbid-ity each due to weight excess.
Results: There was no death. The mean operative time was111,9 minutes (30-380), the mean hospital stay was 4,5 days(3-42).There were 12 conversions (2%), 8 among the 50 firstprocedures. 46 complications required an abdominal reopera-tion (10%) for perforation (n=4),necrosis (n=1), slippage(n=33),reconnection of the tube (n=6) and incisional hernias(n=2). We noticed 7 pulmonary complications (2 ARDS, 5atelectasias) and 35 benign port problems (30 rotations and 5infections ). Slippage happened as a prolapse of the stomachthrough the band ; it was the main late complication (at 11,3months, range 4-22) and required changes in the surgical pro-cedure (pars flaccida approach)and in the device itself. Afterfour years 30 patients had no longer the band (6%), 15 havebeen lost to follow-up (3%). Among the 405 followed during amean time of 12,03months (0-43), in three years B.M.I.fell from43.9 to 30.3kg/m2 and mean E.W.L. reaches 61.9%. 3 patientsamong 55 (5%) had an E.W.L. under 20% after three years.The65 superobese-patients (B.M.I. above 50 kg/m2) obtained aninadequate B.M.I: 42.3 kg/m2 after 1 year (n=31) 37.2 kg/m2
after 2 years (n=24), which does not prevent them from vitalcomplications of their obesity. 43 patients still have no ballooninflation, 201 patients (47%) had one ,the 176 others requiredtwo (n=117),three (n=44), four or more (n=15) readjustments.
Conclusion: Our experience with Lap-Band is encouragingwithout mortality, with an acceptable complication rate. If weexclude superobese patients for whom this operation seems tobe inadequate, more than half of weight excess can be lost inthree years, with comfort , which has never been obtained byany medical treatment. But the procedure is still evolving andthe whole medico-surgical staff has to stay close to eachpatient.
20. LAPAROSCOPIC GASTRIC BANDING: WHYCHANGING TO ANOTHER TECHNIQUE? Ahmed Zayed, MD, Mohammad Al-Jarallah, MD. Armed ForcesHospital Kuwait, State Of Kuwait.
Background: Many authers consider gastric banding as thefirst choice for the surgical treatment of morbid obesity, becauseit is reversible and can be performed laparoscopically. But at thesame time reported morbidity like gastric perforation, band slip-page and pouch dilatation are causes for some concern.
Methods: We started laparoscopic gastric banding in our hos-pital from February 1999 using the Lap Band (AGB,Bioenterics). We inserted the band for 69 patients laparoscopi-cally using the retrogastric dissection technique. FromSeptember 1999 we started to use our safe and easy technique.We inserted the band for 55 patients using this technique.
Results: After using our new technique we eliminated most ofthe complications of retrogastric dissection technique like gas-tric perforation and pouch dilatation.
Conclusion: Our technique is simple and safe guarantees astable and high band position. Our intermediate results aregood.
Background: This study compares, as far as early outcome is
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concerned: a) the Laparoscopic VBG procedure, as originallyperformed (Mason-Mclean type), with creation of gastro – gas-trostomy, division of the gastric pouch and Marlex mesh place-ment, by suturing it to itself and b) a modification of the proce-dure, by Wedge resecting part of the fundus, avoiding the gas-tro-gastrostomy and application of the Marlex mesh, with clipsusing the EndoGIA® (Tyco) instrument.
Methods: 36 morbidly obese patients were included in thisretrospective study. Group A: consisted of 18 patients withGastrogastrostomy, sutures to marlex and using the Endostich®
instrument (Tyco) and Group B: consisted of 18 patients withWedge resection of part of the fundus and EndoGia® (Tyco) tosecure marlex in place. Operative time, conversion rate, intraand postoperative complications, pain and hospital stay wereassessed.
Results:Group A Group B
1.Operative time (mean) 155 min 115 min2.Bleeding 2 Pts ——-3.Conversion 2 Pts ——-4.Pain (Visual analog) 3 35.Atelectasis 3 Pts 1 Pt6.Pneumonia 1 Pt ——-7.Leak 0 0 8.Hospital stay 3 days 3 days
Conclusions: Laparoscopic modification of VBG by Wedgeresection of part of the fundus, thus avoiding gastro-gastros-tomy and the use of Endo-GIA to secure the Marlex reinforce-ment of the gastric outlet in place, significantly decreases oper-ative time and reduces early complications.Therefore it is themost preferred method for laparoscopic vertical banded gastro-plasty for treatment of morbidly obese patients.
22. LAPAROSCOPIC VERTICAL BANDED GASTRO-PLASTY (VBG) - LONG-TERM OUTCOME IN 139 PATIENTS.Torsten Olbers, Hans Lönroth, Jan Dalenbäck*, Eva Haglind,Lars Lundell. Department of Upper G-I Surgery, SahlgrenskaUniversity Hospital and *Frolunda Specialist Hospital,Gothenburg, Sweden.
Background: VBG is a established restrictive bariatric opera-tion that has been frequently used during the last decades.Theoperation has since 1993 been performed by use of laparo-scopic technique at Sahlgrenska University Hospital. The long-term outcome of these patients is hereby presented.
Methods: During the period October 1993 to December 1999139 consecutive patients were operated on with a laparoscopicVBG. Perioperative datas were collected. The patients hasthereafter been followed regularly with respects to weight devel-opment, complications, re-operations and eating disturbances.
Results: Six patients were converted to open surgery due toa large steatotic left liver lobe. Three patients were re-operated;one due to leakage, one due to suspected leakage and onewhere the ventricular tube was caught in the vertical staple line.The mean operation time was 148 minutes (40-315), mean hos-pital stay 3 days (1-13). Both these have been reduced duringthe study period. Eleven patients had a redo procedure. Fivepatients could be considered as primary failures as they neverlost weight sufficiently postoperatively.Three of these had a toolarge pouch as probable cause. One patient has been dilatedbecause of stoma stenosis and another had a verified bandmigration yet without re-operation. In the secondary failures(n=6) has pouch dilatation been the cause in two cases and sta-ple insufficiency in two. Unclear mechanism in the other two.
The weight development corresponds to a 50% reduction ofexcess body weight after 1-2 years postoperatively. Thereafteryou find a tendency to weight regain. About 1/3 of the patientsreported vomiting most often due to overeating.
Conclusion: Laparoscopic VBG can be carried out with lowperioperative morbidity, short hospital stay and fast recovery.The weight development and the frequence of re-operation aswell as the postoperative eating disturbances seems to be com-parable to what earlier has been presented in series with opensurgery.
23. LAPAROSCOPIC VERTICAL BANDED GASTRO-PLASTY: RESULTS ON 250 CASES WITH 5-YEARS FOL-LOW-UP.Mauro Toppino, MD, Mario Morino, MD, Danilo Donati, MD, LucaMazza, MD, Valeria Costamagna, MD. Department of Surgery,University of Turin, Italy
Background: The advantages of laparoscopic approach inmorbidly obese patients have been demonstrated, in particular,with the ASGB, but this operation still presents a high rate oflate complications; gastric by-pass or malabsorbitive proce-dures are feasible by laparoscopy but involve prolonged opera-tive time and a consistent morbidity rate. Laparoscopic VBGcould represent an effective alternative.
Methods: 300 laparoscopic VBG with complete divisionbetween the staple lines were performed since November 1995.The following results are related to the first 250 cases with a 1-5 years follow-up. Average age was 39.3 years, mean weight120.1 Kg, excess weight 209.1%, BMI 45.1 Kg/m2. Forty-fourpatients (17.4%) were superobese. Conversion to openoccurred in 2 case (0.8%). Five cases were conversions to VBGof a previous LASGB (4) or a laparoscopic gastric banding (1).Mean operative time was 95 min. (range 50-210).An associatedoperation was performed in 59 cases (23.6%): cholecistectomy(34 cases), adhesiolysis (15 cases), hiatoplasty (2 cases),umbelical hernia repair (2 cases), band removal (5 cases), cys-togastrostomy for pancreatic cyst (1 case).
Results: Operative mortality rate was nil. Early complicationswere 11/250 (4.4%): 1 leak (reintervention), 5 bleedings (trans-fusions), 3 temporary outlet substenosis (medical therapy), 1subphrenic collection (medical therapy), 1 pulmonary embolism.Late complications were 10/250 (4%): 1 food intolerance forpoor compliance, 1 outlet stenosis with collar erosion (VBGtakedown by laparoscopic approach in both cases), 1 "cascade"pouch with antideclive outlet (conversion in gastric by-pass bylaparoscopy), 4 cases of severe solid food intake troubles (1conversion to lap gastric by-pass), 2 pouch enlargement withgastro-oesophageal reflux (1 conversion to lap gastric by-pass),1 sudden death (m.i.) at one year (patient with poor weightloss). Excess weight loss was: 60.3% at 1 year (194 p), 64.6%at 2 years (121 p), 63% at 3 years (59 p), 61.1% at 4 years (26p), 56.8% at 5 years (11 p). According to Reinhold classification(residual excess weight <50%) a success was achieved in76.9% of the patients after 4 years, without failures; residualBMI was 29.4 at 4 years.
In morbid obese patients EWL at 4 years was 62.2% (22 p),while in superobese EWL was 54.9% (4 p); the success ratewas 77.4% in morbid and 50% in superobese; residual BMI was28.4 in morbid and 35.5 in superobese.
Conclusions: The results on weight loss after laparoscopicVBG compare favourably with literature data and personal datapreviously reported on 218 "open" VBG. The complications rateis low. Considering these results and the wide reduction of peri-
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operative risks due to the coelioscopic approach, the laparo-scopic VBG is, in our opinion, a safe and effective technique inselected morbid obese patients (excluding patients with com-pulsive or sweet eating patterns). On the contrary, results onsuperobese patients or in patients with compulsive eating arequestionable: in these cases a more complex procedure (i.e.gastric by-pass or BPD) should probably be preferred.
24. LAPAROSCOPIC VERTICAL BANDED GASTRO-PLASTY WITH ADJUSTABLE BAND IN THE TREATMENT OFMORBID OBESITY.Giovanni Natalini, MD, Francesco Guiggi, MD, and LucaCalzoni, MD. Department of Surgery, Marsciano-Todi Hospital,Marsciano, Italy
Background: The adjustable silicone band connected to asubcutaneous port improves both early and late results oflaparoscopic vertical gastroplasty in the treatment of morbidobesity. Vertical banded gastroplasty for treatment of morbidobesity is our procedure of choice over malabsorbitive opera-tions because it maintains normal digestion and absorptionwhile eliminating the complications unique to exclusion opera-tions.The addiction of laparoscopy and an adjustable collar hasfurther improved the operation.
Methods: From March 1997 through April 2001, 526 severelyobese patients underwent laparoscopic adjustable verticalbanded gastroplasty ( Lap-AVBG).The operation uses a ten-cmlong vertical, stapled and divided pouch with the adjustableband for a collar. The collar is left open and then after 6 weeksfor healing, the lumen is decreased as required to provide a 2-kg per month weight loss.
Results: There have been no operative deaths. There werethree leaks of the staple line. Four patients had enlargement ofthe pouch from slippage of the collar. This was corrected andsubsequently prevented by imbrication of the stomach wall overthe band anteriorly. Three bands migrated in to the lumen. Fourinfections occurred around the injection port and one of thesewas removed. Seven operations (1.3%) were converted to theopen approach. Mean weight loss was 25.79 kg at one year,37.28 kg at two years and 39.51 at three years. Excess weightloss was 45.52% at one years, 58.20% at two years and 61.82%at three years.
Conclusion: Lap-AVBG makes use of each patient’s needs incalibration of the outlet. This obviates staple line disruption andpouch dilatation from outlet obstruction.The operation is simple,safe,and easy for the patient.The average weight loss achievedat two years is maintained at three years.
25. LAPAROSCOPIC LONG VERTICAL GASTRIC STA-PLING ± SLEEVE GASTRECTOMY FOR THE TREATMENTOF MORBID OBESITY.Simon PL Dexter, Michael J McMahon. Nikos GeorgopoulosLeeds Institute for Minimally Invasive Therapy, The GeneralInfirmary, Leeds, UK
Background: Long vertical gastric stapling without a band(Magenstrasse and Mill operation) is a safe and effective restric-tive procedure for the treatment of morbid obesity. The proce-dure can be performed laparoscopically.The better access thusafforded also allows the redundant stomach to be safelyremoved (sleeve gastrectomy). In this paper we present our ini-tial experience with laparoscopic vertical gastric stapling proce-dures.
Methods: All patients who had laparoscopic bariatric surgerywere entered prospectively onto a database.The database was
reviewed for details of the operation, post-operative recoveryand weight loss during follow up.
Results: Between March 1999 and April 2001 we performedlaparoscopic gastric stapling on 17 patients (15F:2M), 11 ofwhom had a sleeve gastrectomy. The median pre-operative BMIwas 52.1.There were no conversions to open surgery and therewas no mortality. Morbidity occurred in 6 patients (2 staple lineleaks, 1 chest infection, 2 port site infection).The median post-operative hospital stay was 4.5 days.The median BMI at 1, 3, 6and 12 months was 47.7, 43.4, 40,0 and 33.6 respectively.
Conclusion: Laparoscopic vertical gastric stapling is an effec-tive anti-obesity operation, which compares favourably withopen gastric stapling.Resection of the redundant gastric fundusdoes not add morbidity to the procedure.
26. THE GAGNER TECHNIQUE FOR LAPAROSCOPICGASTRIC BYPASS: TECHNICAL OBSERVATIONS ANDDETAILS (Video).Luigi Angrisani; Michele Maresca; Vincenzo Borrelli, GaetanoCimmino, Monica Ciannella Institution: Unit of EndoscopicSurgery, “S.Giovanni Bosco” Hospital, Naples, Italy
The Gagner technique for Laparoscopic Roux-en-Y GastricBypass (LRYGB) has been considered the preferred surgicalmethod to start clinical experience with this procedure.Part 1 ofthis video shows cases in which Blue Methylene Test proved aleakage of the gastroenteric anastomosis: laparoscopic suc-cessful repairs and the single case which was converted tolaparotomy are presented. Part 2 collects various options wehave employed to close the service jejunotomy of the mechani-cal anastomosis obtained by laparoscopic linear stapler device:continous 3/0 silk suture with intra-corporeal knots; interrupted3/0 silk suture with intra-corporeal knots; interrupted 3/0Polyglactin 910 suture with extracorporeal knots; continous 3/0PDS suture lapra-ty; laparoscopic linear stapler. Gastro-entericanastomosis and jejuno-jejunostomy are the main steps ofLRYGB. Complications of these anastomosis may require re-operations leading to potentially lethal conditions. Part 3 of thevideo contains frames of relevant episodes of bleeding and thetechniques used to control them. Bleeding was another com-mon problem encountered during the operation. Although it hasnot been a cause of laparotomic conversion, bleeding has pro-longed the operative time.
27. LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS WITHSILASTIC RING (CAPELLA´S PROCEDURE) IN THE TREAT-MENT OF MORBID OBESITY : TECHNICAL DESCRIPTIONIN VIDEO.Thomas Szegö, MD, PhD; Arthur B. Garrido Jr. MD, PhD;Mitsunori Matsuda, MD, PhD; Carlos José Lazzarini Mendes,MD; Marcelo Roque de Oliveira, MD; Alexandre Elias, MD; LuizVicente Berti, MD. Private Practice - Albert Einstein andBeneficência Portuguesa Hospital, São Paulo- Brazil
The introduction of laparoscopic approach to bariatricsurgery brought similar advantages as seen in general surgery.Performing Roux en Y gastric bypass according to the regulartechniques however, showed less weight loss then achieved inthe open procedure using silastic ring.
In order to get similar results as in open Capella´s procedure,the authors introduced similar technique through laparoscopicapproach.
The selection of patients is done according to the BMI andtype of fat distribution.
Patients with more then 55 in BMI and with typical central fat
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distribution are submitted to open “Capella” procedure andthose that are below 55, with non central fat distribution are indi-cated to laparoscopic Roux en Y gastric by pass.
In this VIDEO, the authors present technical details of theprocedure.
28. LAPAROSCOPIC ISOLATED ROUX-EN-Y GASTRIC BY-PASS: PRELIMINARY EXPERIENCE.A. Restuccia, D. Polito, G. Silecchia,A. Genco, U. Elmore, N.Perrotta, F. Greco, P. Fabiano, N. Basso. Dipartimento di chirur-gia “Paride Stefanini”- Policlinico “Umberto I” Università “LaSapienza” Roma
Background: Roux-en-Y Gastric Bypass has became the goldstandard in USA, due to the well established long term results,including improvement and/or resolution of comorbidities. Onthe basis of our experience on advanced laparoscopy, followingthe technical pittfalls described by Gagner, we started our expe-rience with Laparoscopic Isolated Roux-en-Y Gastric Bypass(LRYGB).
Methods: the multidisciplinary patients selection was basedon the following inclusion criteria: BMI 50-59 (<50 plus dia-betes); failure of previous restrictive bariatric procedure. FromJanuary ‘00 to March ‘01, 14 (4 M, 10 F) consecutive patientsunderwent LRYGB. Mean age 36 (24-53) years; mean BMI 52.6(48-59) kg/m2. One patient had a previous LASGB failure. thepatients presented diabetes. The procedure was performed inaccording to the technique reported by Gagner: six trocars wereused; 15ml isolated gastric pouch from the distal pouch; divisionof proximal jejunum 50cm from Treitz; antecolic and antegastricRoux limb (100cm) with end-to-side gastro-jejunal anastomosisusing 25 EEA stapler; stapled side-to-side jejunojeunostomy.
Results: The mortality was nil. Only 1 patient was convertedto laparotomy due to technical problems of anvil position.Except the converted case, the mean operative time was 338(240-480) minutes. 3 patients developed early post-operativecomplications: wound infection (converted case); prolongedileus; gastro-jejunal fistula (successfully treated with TPN). Onepatient was reoperated 4 months after surgery due to occlusionof the biliary limb (trocar site hernia). The pre-operative BMIdecrease from 52.6 (48-59) to 31.3 (29.6-33.1) respectively at 6and 12 months after surgery.
Conclusions: LRYGB is an advanced laparoscopic procedurerequiring a specific learning curve. The present preliminaryexperience confirms that LRYGB induce a rapid control of dia-betes and other obesity related morbidities.
29. LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS-EVALUATION OF THREE DIFFERENT TECHNIQUES.Essam Abdel Galil, Alla Abbass Sabry**. Department ofsurgery, Ahmed Maher Teaching Hospital* and Ain ShamsUniversity**, Cairo, Egypt.
Background: The Roux-en-y gastric bypass (RYGBP) is oneof the ideal operations for morbid obesity.The minimal invasivelaparoscopic technique have been performed to shorten theoperative time and to reduce the complication rates of the opensurgery.
Methods: During the period from Jan 1999 through Jan 2001an attempt was carried out to perform laparoscopic RYGBP inninety patients.The median age was 30 with a median preoper-ative BMI of 47. The preoperative nutritional habits and comor-bidities were recorded. Laparoscopic RYGBP was done bythree different techniques in three equall groups. In the firstgroup the gastrojejunostomy is constructed by passing the EEA
anvil transorally using a pull-wire technique.In the second groupthe gastrojejunostomy is fashioned with a totally hand-sewntechnique.In the third group the gastrojejunostomy is performedwith an endo-cutter cartridge and the anastomotic incision isclosed with an endo TA stapler.
Results: The results were nearly identical in the three groups,Average excess weight loss at one year was 70%. The meanoperating time was (120 min) in the first group, (100 min) in thesecond group and (75 min) in the third group. Esophageal injurywas the commenest problem in the first group. Incidence of gas-trojejunostomy stenosis was heigher in the second group(36.6%). Incidence of internal hernia was heigher in the second(17%) and first (13.6%) groups than in the third group (3.3%).
Conclusion: Whatever the technique of constructing the gas-trojejunostomy, laparoscopic RYGBP is a safe, effective andtechnically feasible modality for morbid obese patients.We rec-ommend the technique of constructing the gastrojejunostomywith an endo-cutter cartridge and closing the anastomotic inci-sion with an endo TA stapler as it saves time and reduces theincidence of the essential complications in gastric bypasssurgery.
30. FUNCTIONAL GASTRIC BYPASS.Francesco Furbetta, G. Gambinotti.Ospedale di Pescia, Pescia,PT, Italy
Background: Surgery is the only solution for pathological obe-sity. The problem is which operation, for which patient?Gastrorestrictive procedures, malabsorptive and gastrointesti-nal by-pass operations all have selection criteria, results, spe-cific effects and side effects which can be matched with vari-ables like the individual’s adaptation and psycho-physicalresponse to modifications of lifestyle, dietary rules and restric-tions, and to the primary and secondary effects of each opera-tion. Flexibility and adaptability are indispensable to create abond between the technique proposed and the patient if goodresults are to be obtained; since they are hard to define in thepatient, they must be offered by the technique. In the light of thiswe have devised the functional by-pass, which can be activatedand de-activated by inflating or deflating the Lap-Band.
Methods: Positioning of the Lap-Band according to the stan-dard technique, with the addition of hand-sewn side-to-side gas-troenterostomy between the gastric pouch and the intestine inthe form of an Omega loop; inflation and deflation of the Lap-Band allow activation and de-activation of the by-pass. October1995 April 2001 495 lap-band; between January 2001 and April2001 we performed functional bypass operations on 3 patientswith zero morbidity and mortality. Indications:1) After failed Lap-Band treatment.2) May be the first choice operation for patientsindicated for malabsorptive bariatric surgery. Advantages of theprocedure: 1) Laporoscopic approach 2) Reproducibility 3)Reversibility 4) Reduced operative and perioperative risks: a) nocutting and suturing of gastrointestinal tissue b) no excludedlimbs c) no cutting of mesenteric structures.
Results and Conclusion: The chance to activate or disactivatethe bypass itself (whether short or long) allows regulation of theresults and modification of the side effects 2) The chance totransform the Lap-Band into a by-pass operation upgrades it toa first-choice procedure. In the field of pathological obesity char-acterised by an abnormal and variable relationship with food,the flexibility of the functional by-pass operation allows it toadapt to changes in the pathology itself and in the individualpatient, which other surgical techniques cannot do. Surgical via-bility and safety have been shown but long-term efficacy is still
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to be demonstrated.
31. A COMPARATIVE STUDY IN PERCENTAGE OF WEIGHTLOSS BETWEEN LAPAROSCOPIC AND OPEN ROUX-EN-YGASTRIC BYPASS.Constantine P. Spanos, MD, Edward Salzmann, MD, Christa M.Triglio, PA-C Scott A. Shikora, MD. New England MedicalCenter, Boston, MA, USA
Background: Laparoscopic Roux-Y gastric bypass is becom-ing a routine procedure for the treatment of morbid obesity.Fewcomparative studies between laparoscopic Roux-Y gastricbypass (LGB) and open Roux-Y gastric bypass(OGB) havebeen published. The purpose of this study was to evaluate thepercentage of weight loss at the end of the first postoperativeyear after LGB and OGB.
Methods: From December 1998 to April 2000 we retrospec-tively collected data on 39 patients who underwent LGB and 39patients who underwent OGB. The two groups were sorted forage, gender, body mass index (BMI), perioperative complica-tions, length of stay (LOS) and weight loss.
Results: The mean age in the LGB group was 37.31 ± 9.67years vs 43.22 ± 9.51 years in the OGB group. The mean pre-operative BMI in the LGB group was 42.95 ± 3.29 kg/m2 vs45.87 ± 4.19 kg/m2 in the OGB group (p=NS). The preoperativecomorbidity and earlier abdominal surgery were similar in thetwo groups. None of the patients in either group required a stayin the intensive care unit. The mean length of stay in the LGBgroup was 4.47 ± 0.81 days vs 3.85 ± 0.67 days in the OGBgroup (p=0.12). There was no 30-day mortality in either group.At 1-year follow-up, the percentage of excess weight lossshowed no significant difference between the two groups (LGBgroup: 64.65 ± 19.67 vs OGB group: 59.68 ± 19.01, p=0.28).
Conclusion: Laparoscopic Roux-Y bypass is a technicallyfeasible and safe operation which is becoming more popular. Inthis case-controlled comparison the initial results in weight lossare identical, thus confirming the efficacy of LGB.
32. RETROSPECTIVE COMPARISON OF LAPAROSCOPICVERSUS OPEN GASTRIC BYPASS FOR MORBID OBESITY.Anna Uskova, MD, George Bentzel, MD, Devora HathawayBSN, Daniel Gagne MD, Raye Budway MD, Robert Quinlan MD,Phillip Caushaj MD. Dept. of Surgery, Temple University Schoolof Medicine clinical campus at The Western PennsylvaniaHospital,Pittsburgh, Pa. USA
Background: Laparoscopic Roux-en-Y gastric bypass (GBP)is technically possible, and prior studies reflect comparablecomplication rates and outcome with fewer wound problemsthan open GBP. In this review, we evaluate our experience atWestern Pennsylvania Hospital (WPH) with both techniques todetermine safety, efficacy and outcome.
Methods: Data, including demographic, perioperative, andoutcome was retrospectively collected on all patients whounderwent GBP at WPH from Oct 1997 to March 2001. Thisconsisted of 103 patients; 58 laparoscopic, and 45 open cases.All data was compared between the two groups of patientsbased on laparoscopic versus open technique, statistical analy-sis was performed on all appropriate data, and trends wereevaluated.
Results: Both groups displayed similar demographics, includ-ing: age (mean 43), sex (female:male ratio 4:1), preoperativeBMI (laparoscopic group 49.35, open group 53.35 (p = 0.059)).Mean operative time was significantly less in open GBP group(p<0.005), as well as time under anesthesia (p<0.005).
Estimated blood loss was significantly less in the laparoscopicgroup (p<0.005). Length of hospital stay was on average 3.9days for the laparoscopic group and 5.8 days for the open GBPgroup, but this did not approach statistical significance (p=0.16).Overall mortality was < 1%, with one death in the laparoscopicgroup. Morbidity was 21.4% overall, with 18% in the laparo-scopic group, and 3.4% in the open group. Complicationsincluded: anastomotic leak, stricture, bowel obstruction, andwound infection. Follow up to 6 months revealed no significantdifference in weight loss based on operative technique.
Conclusions: Laparoscopic Roux-en-Y gastric bypass is aseffective in achieving weight loss as open GBP, while reducingoperative blood loss and potentially recovery time. Longer oper-ative time and higher morbidity may reflect the learning curve ofthis complex laparoscopic procedure.
33. LAPAROSCOPIC REOPERATION FOR EARLY COMPLI-CATIONS OF LAPAROSCOPIC GASTRIC BYPASS.P. Papasavas, M.S. O’Mara, D. Heathaway, P.F. Caushaj, D.Gagne. Department of Surgery, The Western PennsylvaniaHospital, Temple University Clinical Campus, Pittsburgh,Pennsylvania, USA
Background: Laparoscopic Roux-n-Y gastric bypass is con-sidered the gold standard procedure for morbid obesity. Earlycomplications can be treated successfully with a laparoscopicapproach. We reviewed our experience with laparoscopic re-exploration in the early post-operative period.
Methods: The initial 85 patients who underwent laparoscopicRoux-n-Y gastric bypass by a single surgeon at a training hos-pital were reviewed. All patients who required re-explorationwithin the first 60 days post-op were considered.
Results: Five patients underwent six laparoscopic explo-rations. Mean BMI was 51. Patient one underwent revision forproximal anastomotic obstruction at 58 days post-op. Patienttwo, lysis of adhesions for obstruction 7 days post-op. Patientthree underwent exploration on post-op day two without findingsand proved to have an anastomotic stricture. Patient four wasexplored on post-op day two for revision of the distal anastomo-sis and again four months post-op for reduction of an internalhernia. Patient five developed obstruction at the level of thetransverse mesocolon secondary to cicatrix and requiredlaparoscopic lysis. Four patients recovered without further com-plications and one patient required endoscopic dilatations of theproximal anastomosis.
Conclusions: In the course of treating morbid obesity withlaparoscopic intervention complications will arise. Laparoscopicexploration for early complications is a safe and feasible option.
34. THE ART OF RECYCLING: LAPAROSCOPIC VENTRALHERNIA REPAIR AFTER OPEN ROUX-EN-Y GASTRICBYPASS.Marina S. Kurian, MD, Daniel Marcus, MD and Mitchell S.Roslin, MD. Department of Surgery, Lenox Hill Hospital, NewYork, NY
Background: Open gastric bypass has been shown to have aventral or incisional hernia rate of 12-30%. In the past, thesehave been repaired using an open technique. We present aseries of laparoscopic ventral hernia repairs performed on ourpatients that underwent previous open gastric bypass surgery.
Methods: Prospective collection of data was performed in sixpatients that underwent laparoscopic ventral hernia repair afterprevious open gastric bypass.Three trocars were used for lysisof adhesions. An additional trocar was used to facilitate place-
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ment of the mesh.Results: All six procedures were completed laparoscopically.
Mean pre-bypass BMI was 53.1 and BMI at the time of herniarepair was 33.8. The mean time interval from bypass surgery tohernia repair was 16 months.Mean operative time was 192 min-utes and mean hospital stay was 1.3 days. Mean size of the her-nia defect was 170 cm2 and the size of mesh used was 395cm2. 3/6 patients had a recurrent ventral hernia and 2 of thesepatients had prior open mesh repair. 1/6 patients had a herniaat a site other than the incision for the open bypass procedure.There were no mortalities, and one patient had a suture granu-loma removed ten weeks postoperatively. Mean follow-up periodafter hernia repair is 2.5 months and there are no recurrences.
Conclusions: Laparoscopic ventral hernia repair after opengastric bypass surgery is feasible and can be safely performedin patients with good short-term results.
35. LAPAROSCOPIC VENTRAL HERNIA REPAIR INMORBIDLY OBESE AFTER OPEN ROUX-EN-Y GASTRICBYPASS.Piotr J Gorecki, MD, LD George Angus, MD. Nassau UniversityMedical Center, East Meadow, NY
Three cases of laparoscopic repair of a large ventral herniaafter obesity surgery are shown.The technique is described andthe results are presented.
Conclusion: Laparoscopic ventral hernia repair may be a pre-ferred option for the repair of a large ventral hernia in the mor-bidly obese.This group of patients may particularly benefit fromdecreased incidence of wound complications, shorten recoveryand reduced recurrence rates.
36. LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING INHIGHLY OBESE.F. Aigner, MD, H. Weiss, MD, H. Nehoda, MD, H. Bonatti, MD.Univ. Hospital of Surgery, Dep. of Gen. Surg., Innsbruck, Austria
Background: From Jannuary1996 to April 2001 we implan-tated 401adjustable gastric bands to 381patients(5female:1male, BMI 35-61, mean45).
Method: We used a subcardial implantation technique form-ing a small funduspouch The first 3 cases we did by laparotomythen we changed to laparoscopic technique and had to convertin 3 out of the next 7 cases. After this learning curve convertionwas necessary only 7 times. Mean operationtime was 110min(65-230min), mean hospitalisation p.o.3 days.
Results: 385 times we used the Swedish band (Obtech com-pany/Switzerland), 16 times the Lap-Band ( Bioenterics comp./USA ). Half of the Lap-bands we had to remove due to stoma-narrowing, 6 of them we substituted by a Swedish band. Thisstoma narrowing might have been the consequense of our tech-nique to keep all the fatty tissue around the stomach inside theband to prevent wall-injuries.Therefore the diameter of the Lap-band was to small especially in more obese patients.Patients with BMI<45 needed in the mean 12 month to reach aBMI<30, when BMI was >50 then 24 month. .In 5% we had gen-eral, in 1,5% intraopeative and in 14% late complications, butonly in 12 cases they lead to bandloss and so to a failure of themethod (3%). One patient died due to pulmonal embolism 2month postoperatively.
Conclusion: Adjustable gastric banding is an easy minimallyinvasive method to treat obesity, with a regular weigthreductionand is well accepted by the patients.
37. OUR INITIAL STEPS IN LAPAROSCOPIC BARIATRIC
SURGERY.János Bende,Miklós Ursu,Miklós Csiszár. Péterfy HospitalBudapest Department of Surgery, Budapest, Hungary
Background: The first steps in laparoscopic surgery treatingmorbid obese patients in Hungary were in the year 1999.Ourdepartment decided to use this method the same year, sincetreating these patients in our country conduct the same prob-lems as elsewhere n Europe. With its minimal invasiveness,reversibility and adjustability it seems the right choice in surgery,results are reported good. We perform our early experiences.
Methods: Between May 1999 and March 2001 27 patientsunderwent laparoscopic adjustable gastric banding procedurein our department. 22 men,5 women, the mean age was 47/34-57/46/40-52.Out of the27 operations 17 was LAGB and 10 waswith the Swedish Band.
Results: Our mean operating time was 97 minutes /78-172/,there was no mortality. One reoperation occurred becauseof gastric perforation, otherwise no converting was needed.Thefollow–up showed 36 kg mean weight loss, BMI changing to39.7 kg/m2
Late postoperative complication was 2 port site inflammation,had to be treated surgically.
Conclusion: We are looking forward for good and betterresults treating morbid obese patients with adjustable gastricbanding via laparoscopic technique.
38. BAND EROSION AND SLIPPAGE: DETECTING ANDAVOIDING LONG-TERM COMPLICATIONS.J. A. Lopez Corvala, F. Cordero Guzman, A. A. A. OrtizLagardere. Laparoscopic Group of Baja California, OBCTControl Center, Tijuana, Mexico.
Background: A main concern with LASGB is Band Slippageand Erosion. We present our experience with the complicationand our treatment method.
Patients and Methods: A total of 200 Lap-Band procedureswere performed from September 1996 to December of 2000.Distribution by sex is as follows: Female 73% Male 27%, Age32, (14-62), weight 138kgs (90-222); BMI: 46kg/m2 (35-78).Thefirst 18 procedures in our series were performed with the peri-gastric technique and a 25 cc proximal pouch. The rest of theprocedures were done with the Pars Flacida and the MexicanTechnique and a virtual or 15cc proximal pouch. Complicationsare described as trans-operative, and early and late postopera-tive.
Results: After a four-year experience with Adjustable SiliconeGastric Banding we have experienced complications during andafter the procedure.We had only one trans-operative complica-tion (0.5%) a hemorrhage from a lacerated spleen that did notrequire splenectomy. Early postoperative complications wereencountered in two cases (1%) A large access port hematomathat required drainage, but subsequently had an abscess for-mation and ultimately needed port removal. The second casehad a total stoma obstruction that required a 5-day hospital staywith NPO until gastric edema subsided. No revision or removalof the band was necessary. Late complications were related toAccess ports site infection, recurring infection, abscess forma-tion and chronic fistula in 22 patients (11%) All patients hadaggressive antibiotic therapy, abscess drainage and portremoval if needed. Eight patients developed a chronic fistulaand four had recurring infection. All patients were scoped forsuspicion of band erosion. Late complications related to theband were slippage and erosion. Band slippage presented intwo patients (1%) The first patient, a 45kg/m2 BMI female had
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total oral intake intolerance 12 months after surgery. Bariumswallow demonstrated a band in a low position and a proximalgastric pouch. Band deflation was necessary and liquid diet wasindicated. Two months after, recurrence of symptoms and totalobstruction, required a laparoscopic band removal. Her BMI is34kg/m2 more than a year after her band removal.The secondpatient a 54kg/m2 BMI Female, 12 months after surgery pre-sented a violent vomiting episode during a GI infection. Totalobstruction developed and again a barium swallow demon-strated a slipped band and total stoma obstruction with a largeproximal eccentric pouch. Laparoscopic band removal was indi-cated. Her actual BMI four months after her band removal is31kg/m2. We have encountered eight band erosions (4%) Onlyone was asymptomatic and detected during an endoscopy afterupper GI bleeding from a duodenal ulcer. The other seven pre-sented as recurring port site infection, chronic fistula or loss ofearly satiety. All presented during the first sixteen months afterinitial surgery. Two bands have been removed laparoscopically.Indication for removal was total penetration into the stomachlumen and chronic fistula with no response to antibiotic therapy.Seven of the eight bands have eroded partially (less than 50%of the band penetrating) and have either the outside or loweredge penetrating the stomach into the anterior fundoplication.None have erosion of the buckle or tubing. All patients havevideo-graphic evidence of a floppy anterior fundoplication andpinching of the stomach was ruled out. Three of the band ero-sions had no previous band inflation or adjustment.
Conclusion: LASGB has a low complication rate and in ourseries has no mortality.Band slippage is minimal and has dimin-ished with the higher positioning of the band. Low positioning ofthe band and violent vomiting have been related to band slip-page. Band erosion is un-frequent but should be suspectedwhen recurrent port infection or fistula are present and shouldbe ruled out when the patient has loss of early satiety. AllLASGB patients should undergo routine endoscopy 18 to 24months after initial surgery. In partial band erosion, removal isindicated only when a band has lost its restrictive mechanism orsymptoms are recurrent or uncontrollable with non-surgicalmeasures. Port site complication is frequent and can be treatedwith aggressive antibiotic therapy and will occasionally needport removal for chronic infection or sinus tract. All in all, laparo-scopic adjustable silicone gastric banding has a good and sus-tained weight loss at four years, no mortality, and a re-operationrate of 1.5% in our series.
39. USE OF BIOENTERICS INTRAGASTRIC BALLOONSYSTEM FOR OBESITY TREATMENT.L.J.D.M. Schelfhout MD, PHD. J. Scherpenisse Medical CentreRotterdam Airport D. Gabriels-Verweyen Body Services.Medical Centre Rotterdam Airport, The Netherlands
The BioEnterics Intragastric Balloon (BIB™ System) wasintroduced in a multi disciplinary group treatment for patientswith BMI between 30 and 40.
Since June 2000 we have treated 400 patients and have aone-year follow –up on 35 patients. Standard technique is gas-troscopy and BIB™ System placement under sedation. Directafter placement, the patient is send home. Patients are advisedto drink at least 2 litres water per day. The first days after place-ment the patients routinely are too sick to eat. This problemsolves in 98% of the cases, after a maximum of 5 days. BIB™System’s are removed in the majority of patients after 6 months.The follow-up is organized to start the first week after placementand is a full year program. Patients have dietary advises and
group sessions. Groups are maximum 12 patients and consistof patients with a BIB™ System placed since a few weeks,patients with a balloon placed for a few months and patientswho have the BIB™ System removed, after a six month period.Furthermore the patients have the possibility to have personalcoaching with a NLP trainer.
40. 5-YEAR RESULTS OF LAPAROSCOPIC GASTRICBANDING FOR MORBID OBESITY.M.K.Müller1; M.Weber1; O.Schöb2; L.Krähenbühl1; R.Schlumpf3;R. Hauser4. 1UniversityHospital Zürich; Visceral Surgery, Zürich,2Spital Limmattal; Visceral Surgery, Schlieren, 3KantonsspitalAarau, Department of Surgery, Aarau, 4Consultant for Nutrition,Zürich; Switzerland
Background: We present our 5-year results with the lapro-scopic gastric banding (LAP-Band®). The presented studyanalyses the effect of the gastric banding with special regardsto metabolic changes and perioperative morbidity (infection,slippage, pouch-dilatation).
Methods: Between May 1995 and July 2000 the data of 161laparoscopic implanted gastric banding have been assessedprospectively.The preoperative evaluation included besides thehistory and a clinical status with anthropometry, an impedance-analysis, an indirect calorimetry, blood testing, an ultrasound ofthe abdomen, a gastroscopy, a manometry of the esophagusand a contrast radiography of the esophagus and the stomach.
Results: The mean body-mass-index (BMI) before implanta-tion was 48 kg/m2 (range 34-71); within 3 years the mean BMIwas 37 kg/m2 (range 24-55). The mean fat-mass went downfrom 61 kg to 42 kg, whereas the body-cell-mass changed from40.6 kg to 30 kg.The excessive weight loss after 36 months was42%, the fat-mass-loss was 25%. All gastric bandings could beimplanted laparoscopically with a conversion rate of 0%. In acollective of 149 patients with a follow-up of 5 years, we had toperform a rebanding due pouch-dilatation in 20 cases (13.4%).This procedure could be done laparoscopically in 19 cases.Theperioperative mortality for first and second interventions was 0%in our series.
Conclusions: The laparoscopic implantation of a gastricbanding leads to a successful and on holding reduction of thebody weight with a very small perioperative morbidity and mor-tality. In the longterm follow-up one has to deal with more sec-ondary interventions due to pouch- dilatation, which can bemanaged laparoscopically as well.
41. SWEDISH ADJUSTABLE GASTRIC BAND–REOPERA-TION AND EROSION.Antelmo Sasso Fin. Hospital São Luiz
The show how to take the band out and show how to putagain when the patient has erosion. First step we start the oper-ation at the same point in the first operation by laparoscopicway, by shot dissection even localize the band capsule infected,is recommended the use antibiotic 7 days before the operation.So the capsule is open, the locker is identify and open too, theband is pulled, the hole is closed, we use always drain.
One to three months after, we perform a new operation to puta new band, by laparoscopic way, by shot dissection, even toobtain a safe anatomy. The goldfinger will be better placed if youput it below the lowest point of the right diaphragmatic pillar andabove the left gastric artery tunneling carefully through the oldfibrosis tissue behind the retoperitoneal part of stomach comingthrough the gasrtrophrenic ligament, sometimes it is difficultprenetrate.
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The operator should choose the location must convenient forclose the band, taking care because now the stomach wall isdouble; remembering that later the entire anterior transversediameter of the stomach must be used to establish the tunneland that the wall should only approximate the band looselyallowing only enough space to accommodate inflation of theband without traction on the stomach covering the band.We conclude that erosion of the stomach wall becomes the pro-cedure a little bit difficult but not impossible and we can solvethe problem to these patients.
42. LAP-BAND AND HIATUS HERNIA.Francesco Furbetta, G. Gambinotti.Ospedale di Pescia, Pescia,PT
Background. Epidemiological and endoscopic studies showthat the incidence of gastroesophageal reflux disease(G.E.R.D.) and hiatus hernia (H.H.) are 4-11% and 6-9%,respectively. Furthermore, 32-42% of patients with G.E.R.D.present a H.H., while 20-23% of those with H.H. also haveG.E.R.D.; pathological obesity contributes to the increase inthese conditions.Although a consensus has not yet emerged asto the effects on G.E.R.D. of gastric banding operations forpathological obesity, nor are there endoscopic andpHmanometric data, it is clear that there is a technical problemas to the indication for banding, since a H.H. could causeupward migration of the stomach into the thorax.The aim of thisstudy is to show that laparoscopic positioning of the Lap-Bandsystem (BioEnterics) may be executed concurrently with treat-ment for H.H. and/or G.E.R.D. in adherence to the technicalprinciples of the appropriate procedures and with a theoreticalincrease in the resistance of the gastric pouch to dilation-herni-ation.
Methods: Between October 1995 and April 2001 495 patientswere treated with lap-band (135 males and 360 females) with amean age of 43 years (range 19-75) and a mean B.M.I. of 42.6(range 33-65); all operations were begun and completed laparo-scopically in absence of intraoperative complications and mor-tality; 19 patients showed a H.H., either with or withoutG.E.R.D., of such dimensions as to interfere with correct posi-tioning of the Lap-Band. In the first group (13 patients) we per-formed a posterior cruroplasty together with the Lap-Bandingoperation, and in the second a posterior cruroplasty and fundo-plication (3 Toupet, 2 Nissen, 1 Dor).
Results and Conclusion: In all cases, it proved possible toproceed with a rational and simultaneous treatment of thepathologies in question with no complications, In our experi-ence, H.H. and G.E.R.D. are not counter-indications for the Lap-Band operation, which can be combined with treatment forthese pathologies in adherence to the technical principlesunderlying the surgical procedures. Fundoplication reinforcesthe gastric pouch and eliminates mobility of the fornix of thestomach, reducing the risk of herniation-dilation of the pouch. Atpresent, a large H.H. requires hernia repair for correct position-ing and duration of the Lap-Band in the abdomen, whileG.E.R.D. may be treated with a conventional fundoplication,although controlled studies are required to assess the functionaloutcome of fundoplication in the presence of a Lap-Band.
43. PRELIMINARY RESULTS AFTER COMBINATION OFUSING THE HELIOGAST BAND AND THE TWO STEP TECH-NIQUE TO PREVENT COMPLICATIONS OF THE LAPARO-SCOPIC GASTRIC BANDING.Salomon Benchetrit, MD. Chirurgie Generale et Digestive
Centre (private practice), Lyon, France.Background: One of the bigest problem of the gastric band-
ing is slippage of the band that we can see in more than 10% ofthe case
Methods: We present an alternative technique to facilitateband placement without retrogastric tunneling and a new bandHELIOGAST. Instead of creating the retrogastric tunnel, the sur-geon incises the gastrohepatic ligament at its transparent mem-brane and the first assistant retracts the lesser curvature tissueslaterally and upward. By using blunt dissection the surgeonexposes the crural decussation away from the posterior gastricwall and omental bursa and carries the blunt dissection forwardthe angle of His. A grasper is pulling the Heliogast band and ispositionned under a small gastric pouch. We use this techniquewith the Heliogast band in 130 patients
Results: So far we have performed 130 procedures using thistwo steps technique and this Band. Operating time is now 25 to60 minutes; There were no deaths, no gastric perforation, andno band erosion. On a mean follow up of 6 month there whereno patients with band slippage. Postoperative contrast studiesreveal identical band position as with the traditional retro-gastrictunnel technique. Weight loss matches to what has beendescribed for the retro-gastric technique.
Conclusion: This technique provides a good alternative to theusual retrogastric tunnel dissection.We believe that limiting theposterior dissection and using this circular band is important inpreventing slippage. Our previous experience is in more than500 gastric banding with the Lap-band and the SAGB with arate of slippage of 5% for first 100 cases. The first results withthis combined technique are encouraging us to continue withmore follow up.
44. SWEDISH ADJUSTABLE GASTRIC BANDING INMORBIDLY OBESE: THREE YEARS EXPERIENCE.Hany Aly Nowara, MD, FRCS. Cairo University Hospital &Mokattam Surgery Center
Background: Surgery has been recognized as an effectivelong term treatment for morbid obesity. The purpose of thisstudy is to present an Egyptian experience using the SwedishAdjustable gastric band (SAGB) in cases of morbid obesity afterpassing the learning curve.
Methods: 202 morbidly obese patients having a body massindex (BMI) >40 kg/m2 were included in this study. The proce-dure was performed through a 4 or 5 trocar technique. TheSwedish adjustable gastric band was used in all cases.The portwas placed in the presternal position in most of the cases.Fillingof the balloon was attempted one month after the surgery.
Results: The mean age of the patients was 36.2 years. Themean BMI was 56.2 Kg/m2. The mean hospital stay was 2.3days.The mean BMI after 12 months was 35.2 kg/m2 & after 24months was 33.4 kg/m2. Port complications were noted in 6patients, in the form of infection in 5 patients & bleeding in onepatient. Liver injury occurred in 2 patients & pleural injury in onepatient. Primary band intolerance was seen in one patient & theband was removed laparoscopically. There was no gastric per-foration nor erosions nor slippage in this series.
Conclusions: laparoscopic insertion of the adjustable gastricband proved to be a safe and effective method for the treatmentof morbid obesity in Egyptian patients provided that the surgicalteam had a previous learning curve.
45. LAPAROSCOPIC VERTICAL BANDED GASTRO-PLASTY AND ROUX-EN-Y GASTRIC BYPASS: TWO YEARS
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EXPERIENCE.Cruz F, Cruz JL, Canga J, Gómez P, Martínez JI, Menéndez JM,Yuste P, Villarejo P, Pérez E, Moradiellos J. 12 de OctubreUniversity Hospital (Madrid). León Hospital (León).
Background: The use of the laparoscopic approach to per-form bariatric operations of proven efficacy seems to offer greatadvantages to the morbidly obese patients. Our objective is toevaluate the feasibility of a different laparoscopic gastric bypassoperation.
Methods: Since June 1999 to May 2001, 51 patients havebeen operated on by the same surgical team. Mean age was38,5 years. Weight 129.1 kg. BMI 47.5. Excess weight 103.8%.Eight had cholelithiasis.Three have been cholecystectomized,another three have suffered gynecologic operations and one aumbilical herniorraphy. A laparoscopic vertical banded gastro-plasty and gastric bypass was performed to all the patients,associated to a cholecystectomy in the eight cases referred.
Results: Mean operation time has been 3:58 h. One patient(2%) was converted to open because a methylene blue leak atthe end of the operation. Mortality 1 (2%). Morbidity: 2 anast-motic leaks, 2 upper digestive bleedings, one intraabdominalbleeding, one nasogastric tube entrapment, one wound infec-tion and one urinary infection. The % excess weight loss at 12months has bee 77 %. The mean hospital stay 3,7 days.
Conclusion. Our two years experience shows that this tech-nique of laparoscopic vertical banded gastroplasty and gastricbypass is feasible, safe and it seems that efficacious, althoughit needs great expertise on laparoscopic and bariatric surgery.
46. ESOPHAGEAL DILATION AFTER LAPAROSCOPICADJUSTABLE GASTRIC BANDING: MYTH OR REALITY?Justin R de Jong*, Cas HJ Tiethof**, Robin Timmer***, AndreJPM Smout****, Bert van Ramshorst*. Depts. of Surgery*,Radiology** and Gastroenterology***, St Antonius HospitalNieuwegein Dept. of Gastroenterology**** University MedicalCentre Utrecht, The Netherlands
Background: Oesophageal dilation is an unknown and notfully examined complication following laparoscopic adjustablegastric banding (LASGB).
Methods: Forty-five patients who underwent a LASGB proce-dure between November 1995 and August 1999 were assessedfor the presence of oesophageal dilation. The patients wereanalysed by repeated standardised barium swallow studiesimmediate postoperatively and after a median postoperative fol-low up of 40 months (19-64). For each examination a ratiobetween the maximum oesophagus diameter and band diame-ter was calculated. Symptoms at follow up were assessed by astandardised questionnaire concerning questions about heart-burn, regurgitation, nausea, vomiting , dysphagia, satiety andbelching.
Results: An overall significant increase in the mean oesoph-agus/band ratio (O/B-ratio) was found comparing the immediatepostoperative and long term series (0.52 (SEM 0.02) vs. 0.72(SEM 0.03); p<0.01). In 19.4% a decrease, and in 80.6% of thepatients an increase of O/B-ratio was observed. In 51.7% of thepatients with increase the ratio was between 1 and 1.5, in 6.8%the ratio exceeded 2. A significant correlation between theincrease of O/B-ratio with duration of follow up time (0.389,p=0.02) and severe delay of oesophageal clearance of barium(0.475, p=0.003) was found. Reduction of the band volume in 5patients with severe delay of oesophageal clearance, resulted innormalisation of the O/B ratio (mean oesophagus/band ratio1.6(SEM 0.1) vs. 1.1(SEM 0.1); p=0.002). The increase of O/B-
ratio was only significantly correlated with regurgitation (0.515,p=0.003) and vomiting in the night-time (0.333, p=0.03). Thesesymptoms disappeared after reduction of volume of the band.The amount of ml filling of the band and decrease of BMI dur-ing follow up showed no correlation with the O/B-ratio.
Conclusion: Moderate oesophageal dilation, related withsymptoms in the night-time, was observed in a significant pro-portion of the patients during follow up after LASGB. The dila-tion is fully reversible, by decreasing the volume of the band withdisappearance of symptoms, and seems therefore of little clini-cal relevance.
47. RE-OPERATIONS FOLLOWING LASGB.Ralph Peterli, Andrea Donadini. Peter Tondelli Surgical Clinic,St.Claraspital Basel, Switzerland
Background: Re-operations after laparoscopic adjustablegastric banding operation (LASGB) are either band associatedor due to complications of the access port. Symptoms, diagnos-tics, operations and follow-up of patients with re-operationswere analyzed.
Methods: Between 12/1996 and 4/2001 210 morbidly obesepatients were treated with LASGB and prospectively evaluatedusing a standard protocol. Since 6/00 the pars flaccida tech-nique was applied, since 10/00 with the new 11cm LAPBAND®.All adjustments of the band were done under radiological con-trol.
Results: 35/210 patients had to be re-operated due to bandassociated complications:2x laparoscopic removal of the band(1x due to pain, 1x pouch dilatation); 21x laparoscopic re-gas-tric banding after 13 (3-26) months due to slippage or pouchdilatation; 10x BPD “duodenal switch” after 26 (18-39) monthsdue to pouch and/or esophageal motility disorders (7x) or insuf-ficient weight loss (3x), in 5 cases after having already per-formed a re-banding for slippage. 6 revisions of the access portwere done after 13 (2-27) months due to disconnection of thetube at the port (3x) or dislocation of the port (3x). For patientswith a minimal follow-up of one year the re-operation ratedropped from initially 38% to 14% with an average of 20%. Theearly morbidity of the reoperations were: 1 haematoma in theabdominal wall after re-banding and 1 pulmonary embolism fol-lowing BPD, no deaths. After re-banding 13/21 had an unevent-ful course but 38% had an insufficient band function. No slip-page occurred with patients operated with the new technique.
Conclusion: Re-operations after LASGB for band associatedcomplications remain a frequent problem in spite of a learningcurve but can be performed safely with little morbidity. Changingthe operative technique and with the use of the new 11cm LAP-BAND® the high slippage rate will be reduced.
48. EVALUATION OF 150 PATIENTS WITH LAPAROSCOPICADJUSTABLE GASTRIC BANDING.Casalnuovo Carlos Alberto, Ochoa de Eguileor Ezequiel, RozasHoracio, Panzitta María. Hospital de Clínicas, University ofBuenos Aires, and Private Practice (CCO-Centro de Cirugía dela Obesidad), Buenos Aires, Argentina.
Background: The adjustable gastric banding system (LapBand) is established as a reliable, simple, safe and minimallyinvasive placement for surgical treatment of morbid and super-obese patients.
Material and Methods: The First Bariatric Surgical Programbegan in Argentina in 1988 with non adjustable gastric banding,using laparoscopic approach from 1994 and the laparoscopicadjustable gastric band (Lap-Band) from 1998. In the period
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January 1998 - January 2001, 150 morbid obeses (MO) andsuperobeses (SO) patients were operated on, with 74 % female,mean age 42 years (16-60), mean weight 143 kg. (93-280), 81.1kg. (34-208) of excess weight and a percentage of ideal weightof 231.1%.The initial BMI mean was 52.8 (35-89.3), 56% had aBMI = /> 50 (superobeses, supersuperobeses and triple obe-ses) and 12% = /> 66 (triple obesity). Comorbidities: AHT 63%,Dyslipidemia 58%, Osteoarthritis 53%, OHS/SAS 43%,Diabetes II 34%, Hiatal hernia 22%, Hyperuricemia 25%,Cholelitiasis 25%, and Cardiovascular diseases 13%.
The original perigastric technique was used in the first 30patients with “gastrostenometer” (electronic sensor). We modi-fied the technique in the last 120 patients being able to: a)decrease surgical time, b) avoid complications, c) obtain ahigher and stable band position, d) create a virtual pouch at thebeginning with a very small size later (15-20 cc). As associatesprocedures have been done 3 cholecystectomies (2%) and 10hiatal hernia repair (6.7%).
Results: The operative time in the last 140 patients was 75min. (40-120), and 4 patients were converted to laparotomyamong the first 20 cases. There was no mortality, and the mostimportant complications were the late ones, 2 slippages, 4 port-infections, 1 hemoperitoneum, 1 balloon band leakage and 1gastric wall erosion.Through eight relaparoscopies (5.3%) havebeen treated the major complications, including 3 port infectionsusing a novel technique to place the tube-end far away in anaseptic area.The mean follow-up was 18 months (3-36), with an excessweight loss and BMI (pre 52.8) of 26 % and 47, 43% and 41,61% and 37, 67% and 32, and 67% and 32 at 3, 6, 12, 24 and36 months respectively. The percentage of loss weight betweenmorbid and superobeses patients was similar.A significant resolution of the registered associated illnesses, asmajor and minor medical problems, were observed after weightloss.The incidence of arterial hypertension decrease 33%, obe-sity hypoventilation syndrome 89%, diabetes 82.5% and gas-troesophageal reflux 86%, with a global and important improve-ment in the quality of life.
Conclusions: Although the results of this series appearencouraging, it is necessary a long-term follow up in order toestablish reliable results. The implant of the adjustable gastricband is an advance laparoscopic procedure and the goodresults require a safe and standardized technique. _The stomaadjustment in the postoperative regulates in right form theweight loss with a reasonable tolerance to the food, being thegreat advantage over other gastric restrictive procedures. _Themultidisciplinary approach with programs and special necessi-ties is very important for the treatment of these patients.
49. LONG-TERM EXPERIENCE WITH LAP-BAND SYSTEM.M. Vertruyen. Europe St-Michel Clinic, Brussels, Belgium
Between october 93 and december 2000, 543 patients (487females and 56 males) with a median age of 41 years (range :18 – 65) underwent laparoscopic adjustable silicone gastricbanding using the LAP-BAND® System of BioentericsCorporation.Twenty patients had a previous surgical history ofvertical banded gastroplasty (VBG) with staple line disrup-tion.All patients had been excessively overweight for more than5 years.The mean body weight was 117 kg (range: 95 – 251)corresponding to a mean BMI of 44 kg/m2 (range: 35 – 67).Onthe 543 patients, follow-up was obtained in a period rangingfrom 3 to 86 months (median follow-up : 36 months) in 521patients (95.9%).The perigastric dissection technique was used
in all these cases. In the 121 first cases, the proximal pouch wascalibrated with 25 cc of saline.All the others were calibrated with15 cc.The mean operative time was 60 minutes (range: 20 –180).In 6 cases (1.15%), a conversion to laparotomy was nec-essary (1 left liver hypertrophy, 1 wrong position of trocart , 4severe adhesions due to previous VBG).The mean hospitalisa-tion stay was 1.3 days (range 0 – 7). Specific intraoperativecomplications were gastric perforation (1 case) and bowel per-foration (1 case). These were diagnosed peropertively andtreated by suturing. A short vessel hemorrhage needed a dis-section of the great curvature in order to perform a safe control.In 5 cases, liver dilacerations were observed and treated byspray electrocoagulation. Deep veinous thrombosis occured inone case and basal pneunopathy in 2 cases.The most commonlate complication was total and irreversible food intolerance dueto proximal pouch dilatation, whivh occured in 24 patients (4.6%). Twenty of these cases had previously been calibrated with25 cc and 4 cases with 15 cc. The laparoscopic treatment (in allcases) was the removal of the band in 6 cases, the reduction ofthe dilatation through a closed band in one case and the unlock-ing of the band and its repositioning in 17 cases. In 2 cases(0.4%), the band had to be removed due to psychological intol-erance. Painfull gastric ulceration at the level of the band andresistant to IPP required removal of the band in one case(0.2%). In 5 cases (1%), band erosion with partial intragastricmigration appeared and was treated by laparoscopy withremoval of the band and closure of the perforation. Connectingtube disruption was observed in 15 cases (2.8%). In one othercases (0.2 %) port leakage was detected and a new port wasplaced under local anesthesia. Long term follow-up on 521patients (95.9 %) was obtained at 12, 24, 36, 48, 60, 86 monthswith a mean BMI respectively of 44, 33.2, 31.3, 30.1, 31.4, 31.2and 32.1 kg/m2. LASGB seems to be a safe procedure with alow rate of complications. An acceptable rate of weight loss isobserved at long term . Most of the pouch dilatations can beattributed to a 25 cc pouch calibration.Adhesions after VBG arethe most important reason for conversion.
50. LAP-BAND, SAFE AND EFFECTIVE PROCEDURE: 4YEAR FOLLOW-UP.J. A. Lopez Corvala, F. Cordero Guzman, A. A. A. OrtizLagardere. Laparoscopic Group of Baja California, OBCTControl Center, Tijuana, B.C., Mexico
Background: Adjustable Silicone Gastric Banding procedurefor Morbid Obesity has had its share of bad reviews related tosuccess rate and complications.We describe our results after a4-year experience.
Methods: A total of 200 Lap-Band procedures were per-formed from September 1996 to December 2000. Distributionby sex is as follows: Female 73% Male 27%, Age 32 (14-62),Weight 138 kgs. (90-222); BMI: 46kg/m2 (35-78). Patient preop-erative work-up included Psychological and Nutritional evalua-tion. All patients are approached laparoscopically. Barium swal-low is performed the morning after surgery and patients are dis-charged after 24 hours. We have weekly appointments the firsteight weeks, and psychological and nutritional support is giventhen after every month for the first six months to a year. Bandadjustment is considered on the after the first eight to twelveweeks. Prior psychological and nutritional evaluation is neces-sary. After the first year counseling will vary according to eachpatient.
Results: All of the procedures were completed laparoscopi-cally except two (1%). Technical difficulty was related to exces-
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sive intra-abdominal fat (0.5%) or a very large fatty liver (0.5%).Total surgical time on average was 75 minutes (25-185). ORtime was notably diminished after the first 100 cases where totaltime diminished to 50 minutes.Longer OR time over 90 minuteswere related to BMI larger than 55. The perigastric techniquewas performed in the first 18 patients; we then changed to thepars-flacida and Mexican Technique. Excess body weight losthas been 64% (38-110%) and BMI averaged at 32 Kg/m2 (22-54). We have found a positive relationship between close multi-disciplinary follow-up and weight loss. Forty-eight patients(24%) have never required a band adjustment, and after 18months follow-up (12-36) have lost >50% EBW. The other 152patients (76%) have from 1-4 adjustments.All initial adjustmentsrequire prior nutritional and psychological assessment. Onlyone (0.5%) trans-operative complication was encountered, alacerated spleen which was controlled during the procedurewithout the need of splenectomy. Hospital stay averaged 1.08days (1-5). Prolonged hospital stay was seen in two cases. Thefirst case a 77 BMI patient could not be removed from the ven-tilator.The second case a 55 BMI male had total stoma obstruc-tion in the immediate postoperative period that resolved spon-taneously in the third day after surgery. One early postoperative
complication related to hematoma at the adjustment port siteand late complications at the same level with port site infection,recurrent infection, chronic fistula in 22 patients, (11%) Latecomplications included slippage in two cases (1%) arising 12months after initial surgery. We have detected eight band ero-sions (4%); all have appearing in the first 12 months aftersurgery. Laparoscopic band removal was indicated in twocases. All band erosions were confirmed by upper endoscopy.
Conclusion: The laparoscopic adjustable silicone gastricbanding has proven its value over the years. It is a technicallystraightforward procedure, with a moderate learning curve andlow in transoperatory and post-operative complication rate. It iscomparable in results to other mal-absorptive procedure with alower morbidity and mortality in our series.Band slippage is nowminimal with the change in technique, and even thoughpresently band erosion appears in 4.0% of our patients, it ismandatory to perform a routine endoscopy after 24 months todetect asymptomatic erosions. The overall benefits of LASGBoutweigh the risks by far. We conclude that good surgical teamand technique with a multi-disciplinary support group for longterm follow up will guarantee the success rate and diminish overall complication rate.
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51. ASSESSMENT OF DIFFERENT BARIATRIC OPERA-TIONS: DATA UP TO 5 YEARS FROM THE ITALIAN REG-ISTRY (R.I.C.O.).Mauro Toppino, MD; Michela Mineccia, MD; Silvio Gorrino, MD;*Roberta Siliquini, MD; Francesco Morino, MD; RegistryContributors. Department of Surgery, University of Turin, Italy -*Department of Public Health, University of Turin, Italy
Background: The RICO Registry started on January 1996 inorder to evaluate and compare long term results of differentbariatric operations.
Methods: 5073 interventions were recorded, from 40 Centers,as follows:2015 VBG (39.7%), 1916 ASGB (37.8%), 950 BPD(18.7%), 84 gastric by-pass (1.7%), 56 Bilio-Intestinal By-pass(1.1%), 52 non adjustable gastric banding (1%). Open surgerywas performed in 50.2% of cases and laparoscopy in 49.8%.Among the 40 Centers, only gastric restrictive procedures wereperformed in 18 of them, only malabsorbitive operations in 4,both restrictive and malabsorbitive in 13, restrictive proceduresand gastric by pass in 5. Out of 2515 laparoscopic operations,VBG was performed in 645 cases (25.6%), ASGB in 1786cases (71%), BPD in 55 cases (2.2%), Gastric by-pass in 29cases (1.1%), gastric banding in 9 cases (0.3%).The convertionrate was 6.6% in VBG, 2.8% in ASGB, 8.3% in BPD, 3.3% ingastric by-pass. Average preoperative BMI was 45.3 Kg/m2 inopen VBG, 44.6 in lap VBG, 44.4 in lap ASGB, 48.2 in BPD,51.4 in Gastric by-pass, 48.9 in bilio-intestinal by pass .
Results: Operative mortality rate was 0.35% (0.25% in VBG,0.21% in ASGB, 0.95% in BPD). Early complications occurredin 7.4% of lap VBG, 4.6% of lap ASGB, 9.9% of open VBG,10.1% of BPD. % Excess weight loss (EWL%) in lap VBG was63 at 3 y, 60.4 at 4 y, 56.8 at 5 y.; EWL in lap ASGB was 42.6 at3 y, 41.3 at 4y, 34.6 at 5 y.; EWL in open VBG was 54.1 at 3 y,56.5 at 4 y, 57.3 at 5 y; EWL in BPD was 65.3 at 3 y, 67.5 at 4y, 64.9 at 5 y, EWL in gastric by-pass was 57.9 at 3 y., 53.4 at 4y., EWL in biliointestinal by-pass was 64.7 at 3 y.
According to the Reinhold classification, a success (residual
excess weight <50%), was achieved, at 4 y., in 72.7% of lapVBG, 37.1% of lap ASGB, 51.4% of open VBG, 74% of BPD; afailure (residual excess weight >100%) was observed, at 4 y, in3% of lap VBG, 11.3% of lap ASGB, 5.7% of open VBG, 1% ofBPD. Residual BMI was, at 4 years, 29.7 in lap VBG, 34.9 in lapASGB, 32.9 in open VBG, 29.8 in BPD.
With regard to a morbid vs superobese comparison, a suc-cess was obtained in 79.2% of morbid and 55.6% of super-obese after lap VBG, in 38.3% of morbid and 33.3% of super-obese after lap ASGB, in 53.6% of morbid and 42.9% of super-obese after open VBG, in 75.3% of morbid and 69.6% of super-obese after BPD.
Reoperations occurred in 6.1% of cases, as follows: lap VBG2%, lap ASGB 10.4% (in 6.3% for major complications, such aspouch dilatation, slipping stomach/band, erosions, and 4.1% forreservoir complications, such as leakage, twist, etc.), open VBG3.4%, BPD 3.2%, non adjustable bandings 34.6%.
Conclusions: The RICO Registry allowed us to obtained dataon wide series and compare results between different opera-tions evaluated with the same method. Even with a intermediatefollow-up, better results on weight loss were observed after BPD(expecially with regard to preoperative BMI) and lap VBG too;lap ASGB showed the minor rate of early complications, butresults on weight loss were not so good and the reoperationsrate was still remarkable.
52. VERTICAL BANDED GASTROPLASTY: RESULTS 10YEARS AFTER SURGERY.Papavramidis Spiros, Kesisoglou Isaak, ApostolidisDimosthenis, Gamvros Orestis. 3rd Surg. Dept. AHEPA Hosp.Aristotelian University of Thessaloniki, Greece.
Background: Vertical banded gastroplasty (VGB) and its mod-ifications represents a widely used operation for the last 15-20years.This method is preferred to the most complex operations,as it preserves the normal continuity of the alimentary tract andprevents complications that are common to other bariatric oper-
General Sessions
ations.Methods: Between January 1987 and December 1990, 48
patients with a BMI: 53+22 kg/m2 underwent VGB as a proce-dure of choice for the management of their disease. Patientswere followed-up by clinical, biochemical, hematological, uppergastrointestinal barium meal and/or endoscopy.
Results: Four of the patients died and additional 4 were lostduring the follow up period. So, 40 patients had a complete fol-low-up, at least 10 years after surgery. Using Reinhold’s criteria,the results were very good in 34% of the patients, good in 39%,moderate in 17% and poor in 10%. Six patients who regainedweight underwent a reoperation (two of them biliopancreaticdiversion and four vertical banded gastroplasty with artificialpseudopylorus).
Conclusions: Vertical banded gastroplasty is a safe, and along-term effective operation for severe obesity, producing sat-isfied weight loss ten years at least after surgery.
53. LONGTERM RESULTS AFTER VBG AND LAP-BAND.Husemann, B. Prof. M.D., TH. Sonnenberg Dominikus.Krankenhaus P.O. 290151, D-40528 Dusseldorf/Germany
The analysis is based on a prospective clinical trial on 451patients treated by VBG (82.4% female) and 127 patients with alap band (74.7% female).The minimum follow-up period of timeis 24 months.The weight loss in both groups is comparable:Thepre-op BMI is 49.2 ± 7.0 for the VBG-group and 46,5 ± 7.2 forthe lap-band group. Weight loss is perfect in both groups with aBMI of 34.9 kg/m2 (VGB) and 34.5 (lap-band) after 12 monthsand 30.7 ± 5,7 kg/m2 (VBG) respectively 32 ± 6 (lap-band) after24 months.After five years 46.2% and 43.4% reach a BMI under30 kg/m2, even 20% below 25. As a consequence of the weightloss the patients improve their lab, especially the triglyceride,cholesterol and blood glucose level are normalized. Physicalactivity increases significantly. However there are importantanatomical complications in the long term run: In the VBG-group we have seen 19.3% suture line leats, 2.7% pouch dilata-tion and 8% stoma stenosis, in the lap band groups there are7.8% dislocations, 3.9% penetrations and 2.4% infection of theport or the band. The re-operation rate reaches 17.7% (VBG)and 10.2% (lap-band) after 60 month for bariatric surgery asso-ciated complications.The results for the weight loss are perfectfor both groups, however the rate of reoperations due toanatomical complications is high.
54. LAPAROSCOPIC VERTICAL BANDED GASTRO-PLASTY vs GASTRIC BYPASS – A RANDOMIZED CLINICALTRIAL.Torsten Olbers, Hans Lönroth, Monika F-Olsén, Lars Lundell.Department of Upper GI-Surgery, Sahlgrenska UniversityHospital,Gothenburg, Sweden.
Background: Many techniques are used today in obesitysurgery. Up until now the restrictive procedures such as VBGand the adjustable band has been dominating numerously, atleast in Europe. GBP has within the open surgery establishedas “gold standard” as it combines excellent weight loss with feweating disturbances. Laparoscopic techniques has been devel-oped to perform all the mentioned operations. We hereby pre-sent the perioperative results from a randomised clinical trialbetween totally laparoscopically performed VBG and GBP oper-ations.
Methods: During the period February 2000 to April 2001, 100patients with morbid obesity were, after full consent, ran-domised to VBG (n=51) and GBP (n=49). Perioperative data
were collected.The patients recovery were registered by phys-iotherapist by measurements of lung function and hand-poweras well as consumption of analgetics.
Results: No patients were converted to open surgery. FiveGBP patients were re-operated;two had a laparoscopy becauseof suspected leakage, two had a laparotomy because of bleed-ing where one was intraluminal.One had a laparotomy becauseof a stenosis at the level of the entreoanastomosis. One GBPpatient received blood transfusion postoperatively. After GBPalso one deep infection. One VBG patient was re-operatedlaparoscopically because of a postoperative leakage and there-after developed an abscess. Two VBG patients received bloodtransfusion postoperatively. The postoperative recovery withrespect to analgetic consumption, lung function and hand-power showed only minor differences. The median in hospitalstay was 2-3 days in both groups.
Conclusion: Laparoscopic VBG as well as GBP can be car-ried out with low perioperative morbidity and short in hospitalstay. The number of re-operation in the GBP group was some-what higher (5 vs.1) and the number of major complicationswere also somewhat higher (3 vs.1). As the operative risk inboth groups is low we do not consider that it should be a domi-nating factor in the choice of operation methods but instead thelong-term outcome with respect to weight development andquality of eating.
55. A RANDOMIZED PROSPECTIVE STUDY OF LAP-BANDVS VBG: AN INTERIM ANALYSIS ON THE EFFECTS ONQUALITY OF LIFE AND BMI.Francois van Dielen*, Ghislaine van Mastrigt**, Gemma Voss**,Jan-Willem Greve*. Dept. of General Surgery* and ClinicalEpidemiology and Medical Technology Assessment**,University Hospital of Maastricht
Background: The effects of medical interventions on quality oflife are becoming more and more important. To this end aprospective randomised trial to the effects of LapBand (LB) orVertical banded gastroplasty (VBG) on weight loss and qualityof life (Qol) was performed.
Methods: 52 morbidly obese patients were randomised for LBor VBG. 23 patients (age 36.7 ± 7.4) underwent VBG and 29patients (age 36.1 ± 10.9) underwent a LB operation. BMI, qol(using Euroqol visual analogue scale (vas) and Dolan-algo-rithm) and Nottingham Health Profile 1 (NHP 1) were measuredpreoperative (preop), as well as on 3, 6 and 12 months postop-erative (postop).
Results: One year follow-up results are reported. BMI signifi-cantly decreased (P<0.01) from 47.2 ± 7.1 preop (n=23) to38.1± 6.0 kg/m2 at 3 months (n=23), 33.7 ± 4.7 at 6 months(n=23) and 30.4 ± 5.2 at 12 months (n=15) for the VBG groupand 46.2 ± 5.3 (n=29) to 41.8 ± 5.1 at 3 months (n=29), 38.9 ±5.4 at 6 months (n=29) and 34.6 ± 6.3 at 12 months (n=22) forthe LB group. BMI preop did not differ between both operatedgroups. However, 3 and 6 months postop BMI was significantlydecreased in the VBG group compared to the LB group (p=0.03and p=0.004 respectively).At 12 months BMI did not differ. AfterVBG, Euroqol vas significantly (P<0.05) improved from 52.5 ±24.0 preop to 75.4 ± 18.0 at 3 months, 78.1± 16.7 and 78.5 ±22.2 at 6 and 12 months respectively. After LB, Euroqol vas alsosignificantly increased (P<0.05) from 66.7 ± 19.2 preop to 80.2± 10.9 at 3 months postop and 81.4 ± 12.0 and 79.8 ± 16.2 at6 and 12 months postop respectively. Preop, Euroqol vas wassignificantly different between VBG and LB group. After surgery,improvement of Euroqol vas was equal in both groups. Dolan-
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algorithm and the NHP 1 domains, except domain “pain” for theLB group and the domains “sleep”, “emotion” and “social isola-tion” for the VBG group, significantly (P<0.05) improved. No sig-nificant difference in incremental qol scores (for both Euroqol aswell as NHP 1) was found between VBG and LB group. BMI didnot correlate with quality of life.
Conclusion: In this interim analysis of a prospective ran-domised clinical trial, we demonstrated that at 3, 6 and 12months postoperative a significant improvement of quality of lifeafter both LapBand and VBG was found. Despite a significantdifference in decrease of BMI 3 and 6 months postoperative, nostatistical significant difference in quality of life improvementbetween the VBG and LapBand group was found.
56. LAPAROSCOPIC ADJUSTABLE SILICONE GASTRICBANDING (LASGB) VS LAPAROSCOPIC VERTICALBANDED GASTROPLASTY (LVBG): INTERMEDIATERESULTS OF A PROSPECTIVE, COMPARATIVE, MULTI-CENTER TRIAL.N Basso, F Favretti*, M Morino**,U Parini***, G. Silecchia, ARestuccia, U. Elmore, , M Toppino**. Dipartimento di chirurgia“Paride Stefanini”- Policlinico “Umberto I” Università “LaSapienza” Roma”, *Dipartimento Chirurgia Generale Osp S.Bortolo - Vicenza (ASL 6 Veneto), **Divisione Chirurgia -Università di Torino, ***U.O. Chirurgia Generale - OspedaleRegionale Valle d’Aosta
Background: the adjustable gastric banding and verticalbanded gastroplasty represent the most widely used laparo-scopic bariatric restrictive procedures. No prospective studycomparing the two laparoscopic procedures is available. Theaim of the present study was to compare two standard laparo-scopic procedures: LapVBG sec MacLean versus LASGB(LapBand Bioenterics-McGhan®), analyzing safety and efficacy at24 months follow-up.
Methods: design of the study: closed prospective multicenter(Turin-Aosta: LVBG; Rome-Vicenza: LASGB) comparative trial:2 homogeneous groups (100 pts x arm). Inclusion criteria:A.S.B.S. criteria, age 18-65 yrs; BMI 40-50 (35-49 if comorbidi-ties). The follow-up data until 24 months p.o. were analyzed.
Results: From June 1997 to Dec 1998, 233 pts (191 F, 42 M),mean age 37.8 (18-65) yrs, mean BMI 43.4 (36-50), wereenrolled. Comorbidities were present in 61.4% of LASGB ptsand in 89% of LVBG pts respectively. The operative results forLASGB (132 pts) and LVBG (101) were: mortality null in bothgroups; operative time 82.7 vs 93.5 minutes ; conversion rate1.5% vs nil; intra and post. op. morbidity 0.7% vs 7.8%; p.o. hos-pital stay 2.2 vs 6.3 days. The drop at 24 months was 15%. Thereoperation rate, the BMI and %EWL at 24 months were respec-tively:6.8%, 33.6 and 42.5% in LASGB group; 1%, 29.6 and63.2% in LVBG group. The comorbidities improved or resolvedin 73% (LASGB) and 77.4 % (LVBG).
Conclusions: Both laparoscopic procedures were safe. Earlymorbidity was higher in LVBG group (7.8 vs 0.7%). At 24 monthsfollow-up: the LASGB group showed a higher reoperation rate(6.8% vs 1%); the EWL was significantly higher il LVBG group(63.2% vs 42.5); the results regarding the comorbiditiesimprovement or resolution were similar between the two groups.
57. 2010 OPERATIONS FOR OBESITY IN THE SWEDISHSOS STUDY: METHODS, HOSPITAL TIME AND COMPLICA-TIONS.J. Hedenbro1, I. Näslund2, G. Ågren2, A. K. Lindroos3, L.Sjöström3. Depts. of Surgery at Lund1 and Örebro2 University
hospitals and the SOS secretariat, Göteborg3
Background: The Swedish SOS study has survival benefitfrom surgery as its primary end-point. There are several sec-ondary end-points.The power analysis was originally based onan operative mortality of 0.5%; 10 years of follow-up on 2000operated patients and 2000 obese control subjects should thensuffice for statistically significant conclusions to be reached onsurvival.
Method: in the period Nov. 1987 to Jan. 2001 we performed2010 patients at altogether 26 participating surgical depart-ments.Two special protocols (operation and hospital time resp.)were filled out for all operated patients. This database wassearched for demographic data, and for differences betweenprocedures, techniques as well as between departments.
Results: There were 1490 women, 520 men. Mean BMI atoperation was 41.3 for men and 42.8 for women. Antibiotic pro-phylaxis was used in 96%, thrombosis prophylaxis in 99%. Thenumber of operations per department varied between 7 and241. Ten depts. performed <50 operations each, total 264. Tendepts. performed 51-100 operations each, total 707, and 6depts. performed >100 operations each, total 1039. The openapproach dominated (89.2%). VBG dominated as method(n=1368) followed by 377 gastric banding and 265 gastricbypass operations. Mean operative time was longest for laparo-scopic gastric bypass (177 min.) and shortest for open gastricbanding (66 min.). There were no clear differences betweentype of hospital and op. times. However, the trend was clear thathospitals with the largest number of operations in this materialalso had shorter operative times, as well as hospital times.Thislatter finding was coupled to a more rapid return to oral alimen-tation. The last 1000 patients in the series had on average oneday shorter hospital time than the first 1000. Laparoscopicapproach gave a shorter hosp. time (4.4 days) than open tech-nique (7.6 days). Perioperative complications were 26 opera-tions with a blood loss >1000 ml, most commonly due to splenicdamage necessitating splenectomy (n=16; 0.8%). Reoperationfrequency was 2.5%; higher for laparoscopic procedures (6%)than for open (2.1%). 222 patients (11.0%) had one or morecomplications prolonging hospital time with >24 hours; mostcommonly infectious and respiratory.
Conclusion: Operations for morbid obesity can be performedsafely, and with short operative and hospital times. Increasedexperience with this patient group and the operative methodsseems to increase efficacy. The laparoscopic approach hasmore reoperations but a shorter hospital time.The value of obe-sity surgery depends on the results on obesity and and its com-plications.Even small benefits are likely to justify surgery.
58. BARIATRIC SURGERY FOR THE SUPER OBESE :WHAT IS THE BEST OPERATION?Joseph F. Capella, MD, Rafael F. Capella, MD. HackensackUniversity Medical Center, Hackensack, New Jersey, USA.
Background: Proximal roux-en-Y gastric bypass has beenreported to be ineffective in roducing weight loss in the super-obese patient (³ 225% of ideal weight). Malabsorption proc-dures have been recommended by several authors for thispatients group. We studie d 247 individuals. Who underwent acompbination of vertical banded gastroplasty and roux-en-ygastric bypass (VBG-RGB).
Methods: The study involves 247 consecutive VBG-RGB’s on247 super-obese individuals.Data was obtained from 30 of the41 eligible patients at 5 years for a perchentage follow-up of 73.The 30 patients had an initial BMI of 60±8 and an average
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weight of 170 kilos (375lbs)Results: At five year follow up the average BMI of the 30
patients was 32±6 with a percentage excess weight loss of74%. Only two patients lost less than 50% of their excess weight(7%).
Conclusions: VBG-RGB has been effective in producing sat-isfactory weight loss in superobese individuals at five years. Wefeel that VBG-RGB should be offered as a primary procedure forsuper-obese individuals.The few patients who fail to lose morethan 50% of excess weight may be candidates for a malabsorp-tion procedure that can easily added to VBG-RGB.
59. MALABSORPTIVE GASTRIC BYPASS IN PATIENTSWITH SUPER OBESITY: COMPARATIVE STUDY OF ROUXLIMB LENGTH.Robert E. Brolin MD, Lisa B. Lamarca MS, R.D. Ronald P. Cody,EdD. St.Peter’s Univ Hospital and UMDNJ-RW Johnson MedSch,New Brunswick, NJ, USA
Super obesity has been defined as ³200 lb overweight or asa BMI ³50 kg/m2. Weight loss results in super obese patientshave been problematic after gastric restrictive operations includ-ing conventional short limb RY gastric bypass (RYGB). An ear-lier report showed that a 150cm Roux limb produced signifi-cantly greater weight loss vs. a 75cm Roux limb in super obesepatients. However, recidivism after 3 years was common in bothgroups. The goal of the present prospective study was to com-pare weight loss using a distal RYGB (D-RY) in which the RYanastomosis was performed 75cm proximal to the ileocecaljunction (N=47) vs super obese patients who had Roux limbs of150cm (N=152)and 50-75cm (N=99). All operations incorpo-rated the same gastric restrictive parameters and were per-formed by one surgeon. Minimum follow up period was 3 yearsand ranged to 16 years. Weight loss and reduction in BMI weresignificantly greater after D-RY vs. both RYGB-150, RYGB-75and in RYGB-150 vs. RYGB-75 through 5 years. Mean percentexcess weight loss peaked at 63% after DRY and RYGB-150 vs55% after RYGB-75. Weight loss maintenance through 5 yearswas correlated with Roux limb length with DRY >RYGB-150>RYGB-75. More than 75% of obesity-related comorbiditiesimproved or resolved with weight loss. There was no differencein early postop morbidity rate: 8.7% after D-RY; 8.5% afterRYGB-150; 2.0% after RYGB-75 with one death (0.3%) frompulmonary embolism after RYGB-150. Diarrhea was noted in 17patients (36%) after D-RY; in one patient (0.3%) after RYGB-150 and absent after RYGB-75. All D-RY patients had at leastone postop metabolic abnormality.The incidence of anemia wassignificantly greater after D-RY vs. RYGB-150 and RYGB-75 (p< 0.05 D-RY vs. others). There was no difference in the inci-dence of metabolic sequelae between RYGB-150 and RYGB-75patients. No operations were reversed or modified for nutritionalcomplications.Two D-RY patients required TPN for protein calo-rie malnutrition.These results show that Roux limb length has asignificant impact on weight loss in super obese patients.However, it is unclear whether the superior weight loss andweight loss maintenance after D-RY in comparison with RYGB-150 is sufficient justification for its routine use in superobesepatients having bariatric operations. We conclude that somedegree of malabsorption should be incorporated in bariatricoperations performed in super obese patients in order toachieve satisfactory long term weight loss.
60. PROSPECTIVE EVALUATION OF THE FOBI-POUCHOPERATION FOR OBESITY: A SIX-YEAR FOLLOW-UP
REPORT.MAL Fobi, MD, FACS. Center For Surgical Treatment OfObesity, Tri-City Regional Medical Center, Hawaiian Gardens,USA
Background: Prospective Evaluation of the Fobi-PouchOperation for Obesity.
Method: The Fobi-Pouch Operation for Obesity is a gastricbypass with a banded, vertically transected 10-30cc estimatedpouch, with short Roux-en-Y Limbs. The efferent limb, used asa serosal patch to the cut edge of the pouch, is interposedbetween the pouch and the bypassed Stomach. The gastro-enterostomy is distal to the band. A gastrostomy tube, and aradio-opaque Marker at the gastrostomy site to facilitate accessto the bypassed segment, completes the Operation. All patientswho had the primary Fobi Pouch Operation for Obesity atCedars Sinai Medical Center in Los Angeles and at BellwoodGeneral Hospital in Bellflower, California, from January 1stthrough December 31st 1994, have been followed prospectivelyto determine the outcome of this operation in the treatment ofobesity.
Results: Two hundred and seven patients had the Fobi-PouchOperation as a primary operation in 1994. Nineteen men and188 women were operated upon.The age range was from 16 to74 years with a mean of 40 years. The BMI was from 34 to 78with a mean of 47.3. The follow up rate at six years is 67%. Peri-operative complications occurred in 18 patients (9%) with nomortality. Late complications include 41 ventral incisional her-nias, 7 Cholelithiasis, 9 patients with excessive weight lossand/or solid food intolerance, 6 small bowel obstruction, 5 withgastro-gastric fistula, 4 band erosions, 3 gastro-jejunal fistula, 2marginal ulcers and at this time an indeterminate number withcalcium, iron and vitamins A, D, E, B-1, B-6 and B-12 deficien-cies.The average percentage excess weight loss at six years is67.2%, with a range of 29-113%. Most co-morbid conditionshave been significantly ameliorated.
Conclusion: The Fobi–Pouch Operation for Obesity producesexcellent weight loss and maintenance with comparable accept-able side effects in morbidly obese patients.
61. EFFECTS OF LAPAROSCOPIC GASTRIC BANDING ONBODY COMPOSITION, METABOLIC PROFILE AND NUTRI-TIONAL STATUS IN MORBID OBESITY: 12 MONTHS FOL-LOW-UP.V. Giusti1, M. Suter2, E. Zysset1, E. Héraïef1, R. C. Gaillard1, P.Burckhardt1. Department of internal medicine1 and surgery2,University Hospital - CHUV, Lausanne, Switzerland
Background: The significant weight loss which is usuallyobserved during the first 6-12 months after gastric banding isdue to an important reduction of food intake, with a potential riskof minerals and vitamins deficiency.The aim of this study is toevaluate the effects of gastric banding on total body composi-tion, nutritional status and metabolic profile.
Methods: We studied 31 women with a median age of 36years who underwent laparoscopic gastric banding. Total bodycomposition was measured before, 6 and 12 months afterlaparoscopic gastric banding, using dual-energy x-ray absorp-tiometry (Hologic QDR 2000). Metabolic profile and nutritionalwere evaluated before and 1, 3, 6, 9 and 12 months postopera-tively.
Results: body compositionWeight BMI Fat FFM Waist Hip EBW
Conclusions: There was a 23% reduction of total body weight,a 37% reduction of body fat, a 10% reduction Fat Free Mass(FFM), and a significant improvement of the metabolic profile.Modifications of body composition were maximal during the first6 months. The degree of weight loss was correlated to initialbody weight and was more important in patients with abdominalobesity. Reduction of FFM was positively correlated to waist cir-cumference (p< 0.0001).There was no evidence of vitamins andminerals deficiency 1 year after gastric banding.
62. FLEXIBLE GASTRIC BAND: SUCCESS OF INTERDIS-CIPLINARY TEAM-WORK? Ricklin Thomas P.*, Potoczna Natascha*, Piec Grazyna*,Steffen RudolfX, Horber Fritz F.* X. *Clinic Hirslanden Zürich,XOBEX-Institutes, Zürich and Bern, Switzerland
Background: The definition of success of bariatric surgeryshould include weight loss results, improvement in quality of life,reduction of comorbidities and rate of peri- and postoperativecomplications. In 1996, BAROS (Bariatric Analysis andReporting System) was introduced and published by Oria et al.(Obesity Surgery 1998;8;487-99). This standardised scoringsystem allows quantitative comparisons to be made betweendifferent methods and institutes.
Methods: Between 22.2.1996 and 30.10.1999, 249 patientsunderwent implantation of a Swedish adjustable gastric band,using a standardised technique. After two years, 199 patients(81% female, 19% male, mean age 42 years, age range 18-70years) with BMI 41.8kg/m2 (±0.3; SEM) were evaluated usingthe BAROS questionnaire, but 50 patients (20%) had notanswered the questionnaire, yet. However, there was no differ-
ence in postoperative weight loss between the two groups.Results: The BAROS scores (maximum 3 points each) were
“Weight loss % of excess”: 1.86 ± 0.05 , “Comorbidities”: 1.70 ±0.07, “Quality of life”: 1.59 ± 0.05. “Complications”: -0.09 ± 0.04;total score 5.00 ± 0.12. 23.1% of patients demonstrated anexcellent result (score 7-9 points), 62.8% good (score 4-6points) and 12.6% a fair result (score <0 points) .The failure ratewas 1.5%. A major problem with the BAROS score is the under-estimation of patients without comorbidities, affecting the youngparticularly, because they miss 3 points already at time of oper-ation (Patients with comorbidities (n=161): 5.30±0.11 vs nocomborbities (n=38): 3.30±0.21, p<0.001).
Conclusion: Gastric banding results in excellent weight loss,improving quality of life with a low complication rate and signifi-cantly reducing the overall rate of comorbidities.More than 98%of patients demonstrated at least a fair result whilst more than85% of patients showed a good or excellent result, using a teamapproach comprising bariatric surgeon, obesity specialist, dietit-ian and psychologist.
63. LAPAROSCOPIC GASTRIC BANDING: ONE SUR-GEON, 400 CASES, RESULTS AND COMPLICATIONS.Paul Anderson. Oarlunga Hospital and Ashford Obesity Clinic,Adelaide, South Australia
Background: 400 hundred cases operated on by one sur-geon[ the author] are reviewed over a 4 year period.
Methods: The Lap Band (Bioenterics) was inserted in378 obese patients as a laparoscopic operation.The band wasinserted at the esophagogastric junction using the pars flaccidaapproach. Of these 13 had a large hiatus hernia which waslaparoscopically repaired with a cruraplasty and gastrodesis.[6patients had laparoscopic conversion of a gastroplasty].In theremaining 22 patients an open procedure was utilised to facili-tate conversion of previous gastric bypass or gastroplasty.TheLap Band was inserted in the same position.
Results: The cohort comprised 85% females and 15%males.Mean age was 41 with a range 15-70 yrs. Mean present-ing BMI was male 43.4 and female 42.1. Current BMI male 35.7/female 34.6.The mean presenting weight was 116Kg. Meanloss at 12months was 24Kg with a mean loss per month of 2.2Kg .Mean excess weight loss was 50%.Complications: gastric perforation 5 1.3%[3 perforations- microperforations secondary to sutures,{Bandremoved} 1 perforation secondary to slippage requiring partialgastrectomy and Band removal, 1 perforation due to erosion ofBand/, Band removed laparoscopically, replacement Band at 6months and 1 gastric perforation at time of band insertion,laparoscopically sutured]Band leakage 1 <1% Wound Haematoma 2 <1%Wound Infection 6 1.5% Port site infection 6 1.5%Port site fracture 2 0.5% Port casing split 2 0.5%Port tubing leak 2 0.5%[all port related complications repaired local/sedation]Pulmonary Embolus 1 <1%[warfarinised for 6 months no further sequealae]Slippage 20 5%Anterior Slippage 8 2%Posterior Slippage 12 3.1%
Conclusion: Use of the laparoscopic gastric band { Lap Band}is a minimally invasive approach to the problem of obesity.Placement of the Lap Band at the esophagogastricjunction reduces the potential for posterior slippage. It providesan approach to the problem of obesity which is relatively low risk
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64. LAPAROSCOPIC VERTICAL GASTRIC BANDING –FIVE YEARS EXPERIENCE.Eliezer Avinoah MD, Leonid Lansdberg MD, Solly Mizrahi MD.Surgery A, Soroka Medical Center, Faculty of Health Sciences,Ben-Gurion University, Beer-Sheva, Israel
500 morbidly obese patients underwent laparoscopic gastricbanding during 1996 to 2001.Their mean age was 38±9 (rangefrom 12 to 67 years) years old and their BMI (body mass index)44 ± 7. There were 156 males and 344 (69%) females. Sixty(12%) patients had diabetes and 75 (15%) patients had essen-tial hypertension, 126 patients (82% of the males) had sleepapnea syndrome. Four patients required convertion to opensurgery, because of technical difficulties. Duration of operationat the first 250 patients was 80 ± 25 minutes, while at the last250 patients it declined to 39 ± 22 minutes. The band wasinserted through the gastro-phrenic ligament from the angle ofHis to the lesser curve and fixed under the fundus. There wasno mortality. Four patients had misplaced band and were reop-erated two to three days after surgery. Themean hospital stay after surgery was 22 ± 13 hours. Eight to 14months after surgery 21(4.2%) patients had band slippage. 12patients of them had gastric band obstruction and underwentlaparoscopic reposition. Gradual inflation of the band inducedgradual adaptation. Only ten percent of the patients reported ofrecurrent vomiting.The mean BMI five years after surgery is 28± 7, six patients of whom had laparoscopic band extraction.Ourconclusion is that laparoscopic gastric banding is an effectiveoperation with very low morbidity.
65. SAFETY AND FEASIBILITY OF LAGB FOLLOWINGPREVIOUS FAILED SRVG.Subhi Abu-Abeid, Ann Gorevich and Amir Szold. Surgery B,Bariatric Surgery and advanced laparoscopic Surgery Unit, Tel-Aviv, Suorasky Medical Center, Tel-Aviv, Israel
Gastric Restriction is the most common operation done formorbid obesity outside the U.S.A.This operation can be done bylaparoscopy or laparotomy and include various gastric bandingprocedures and vertical gastroplasties ( VBG,SRVG).
At least third of vertical gastroplasties will develop on a laterstage stapler line disruption, pouch dilatation and rarely siliconring widening or migration, these patients will eventually gainweight, and the question how can we help them overcome thislife threatening situation. 13 patient (9M, 4F) who underwentprevious SRVG’s (3 Æ15 years) (mean 6.5 years) were referreddue to weight gain. Upper GI series showed stapler line disrup-tion in 8, pouch dilatation in 4 and stoma enlargement in 1patient. All patient were operated through an upper midline inci-sion. In all patients the repair was performed laparoscopically,adhesions were released and lap band was placed just belowthe G-E junction.There were no intraoperative complications, noconversion and patients were discharged whith in 24 hours. theshort term results seems to be more than expected .Although it’s a small number of patients, it seems that previousfailed gastric restriction operations can be done safely bylaparascopically .Longer follow up and more patients areneeded to evaluate the long term result’s in this subgroup.
Background: Minimal invasive surgery is a great improvement
in the field of bariatric surgery. The aim of this study was toassess the effect of laparoscopic treatment of complicationslinked to Vertical Banded Gastroplasty.
Methods: In a prospective study the outcome of patients withreoperation after VBG were analyzed. All reoperations fromSeptember 1999 onward were planed laparoscopically. TheLAP-BAND System (LAGB) and the Swedish Adjustable GastricBanding (SAGB) are performed as laparoscopic procedures inthe treatment of complications after VBG.
Results: Between September 1999 and April 2001 we oper-ated 24 patients, who were admitted for a reoperation after VBGinitially via laparotomy. All reoperations were planed laparo-scopically. Six out of the 24 patients (25%) had multiple opera-tions. Indications for reoperations were: Nine patients (37%)with outlet stenoses and recurrent vomiting and 15 patients withstaple line disruption.The mean BMI prior treatment was 46.2 ±5.4 kg/m2. The mean BMI decreased statistically significant untilthe complication occurred 34 ± 6.3 kg/m2. We noted no periop-erative complications and no conversion to open surgery,respectively. The mean duration of operation were 85 ± 14 min-utes and the hospital stay 4.2 ± 1.3 days. The mean follow-upwere 14 ± 5,4 months and the current follow up rate is 96%.Thestrategy and technique of laparoscopic complication manage-ment will be described in the presentation.
Conclusion: The treatment of complications after VBG withLaparoscopic Adjustable Gastric Banding (LAGB and SAGB) issafe and effective.
67. CONTRACEPTIVE THERAPY AFTER BILIO-PANCRE-ATIC DIVERSION IN THE TREATMENT OF MORBIDOBESITY.R. Ceulemans, E. Gerrits, L. Hendrickx, E. Totté, R. Van HeeAcademic Surgical Centre Stuivenberg, Antwerp, Belgium
Background: An important population of patients who under-went a biliopancreatic diversion are fertile women.We would liketo demonstrate the need for consensus with regard to contra-ceptive therapy after biliopancreatic diversion by evaluating therisks of pregnancy, the safety of oral contraception and thechanges in fertility after this type of obesity surgery.
Methods: From May 1997 till May 1998 forty-one womenwere included in a prospective study evaluating the hormonestatus preoperatively and postoperatively on day 2, day 7, after3 months, 6 months and 1 year. Women younger than 16 orolder than 44 years of age were excluded. One patient had atotal hysterectomy. All of the patients underwent a biliopancre-atic diversion as described by Scopinaro with the modification ofa 60 cm common limb.The three surgeons were free to choosethe type of contraceptive therapy. An extensive questionnaire,queering the fertility and obstetric history, was send at least twoyears after inclusion. A literature search was performed tounderstand the complex physiology of hormone changes afterexcessive weight loss and absorption and metabolism of oralcontraception in case of postoperative complications.
Results: Evidence, found in literature, shows that rise in con-centration of SHBG, FSH and LH and decreasing levels ofserum testosterone and DHEA-sulphate resulting in animproved fertility status, is regulated through complex interac-tions as with the GnRH-pulsgenerator. In case of excessiveweight loss, vomiting and diarrhoea oral contraception is lesssafe. In case of postoperative complications a pregnancy mayenhance the morbidity of the patient and child as spina bifida incase of folic acid deficiency. The lab results in our study indi-cated the same trend in hormone changes as mentioned above.
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The questionnaire shows the use of 5 different types of contra-ception where 9 patients used solely oral contraception. Fromthose, 2 patients (22%) developed an unforeseen pregnancy.For both it was their first child. From 4 patients using no contra-ception 2 got pregnant within 12 months after the operation.From the 4 pregnant women 1 developed anaemia and 1 vita-min deficiency. Although abortion and child complications wereseen in other patients in our hospital, none of these problemswere seen in our study. There were no obvious changes in thepatient’s menstrual cycle or sexual activity.
Conclusion: Although, in our small study group, no pregnancyrelated complications were seen, literature shows that preg-nancy should be avoided within 6 to 12 months after biliopan-creatic diversion because of rare but potentially severe compli-cations for the mother and child.The fertility, as indicated by theworld literature and confirmed in our study, is better after bil-iopancreatic diversion. Oral contraception is less reliable.Thereis at present no consensus about the use of contraceptive ther-apy. We strongly believe that large multi-centre, prospective,randomised trials are necessary to confirm our feeling that oralcontraception should be avoided at least 6 to 12 months afterbiliopancreatic diversion.
68. SHORT TERM COMPARISON OF “LONG-LIMB” ROUX-EN-Y GASTRIC BYPASS VERSUS BILIARY PANCREATICDIVERSION WITH “DUODENAL SWITCH”.T. Daskalakis, J. Nicastro, H. Mcmullen, S. Bianchi, M. Pagala,G. Coppa, J. N. Cunningham, J. Macura. Staten IslandUniversity Hospital, Staten Island, NY and Maimonides MedicalCenter, Brooklyn, NY, USA
One hundred forty-three consecutive procedures for morbidobesity performed at our institutions between October 1, 1999and October 1, 2000 were reviewed. Of these, ninety-three were“long-limb” Roux en Y Gastric Bypasses (LLRYGB) and fiftywere biliary-pancreatic diversions with “duodenal switch (DS)”.
We compared the two procedures in terms of hospital lengthof stay, complications, and early weight loss. In terms of weightloss, we further subdivided the groups into 3 levels of morbidobesity based on their Body Mass Indexes. A stastical analysisusing unpaired t-test and z-test were performed to evaluate ourresults.
We found that the DS is associated with, a slightly longerhospital length of stay, 6.08 days vs. 3.88 days (p<0.001), and ahigher incidence of superficial wound infections compared toLLRYGB, 10.00% vs. 1.07% (p<0.020). Among all patients, thedecrease in BMI and weight loss rate is comparable. In males,there is a statistically significant greater decrease in BMI in theLLRGYB patients than in DS patients up to 12 months, while infemales it is comparable. By subdividing the patients into 3 lev-els of BMIs (<50, 50-60, >60), there was no significant decreasein the DS patients. The LLRYGB patients with <50 BMI had agreater decrease in BMI at 12 months compared to patients withBMI of 50-60 and a greater decrease in BMI at 1 month and at12 months compared to patients with BMI>60.
At this early follow-up, DS does not demonstrate an advan-tage in terms of weight loss over LLRYGB. As expected, hospi-tal length of stay is somewhat greater. Complications are com-parable with a slight increase in superficial wound infections.The graphic representation of weight loss suggests that ourresults may change significantly with further follow-up and re-evaluation at the 18-24 month probably is warranted.
69. BILIOPANCREATIC DIVERSION (BPD) FOR SEVERE
OBESITY: COMPARISON AT ONE YEAR OF SCOPINARO’SBPD AND BPD WITH TRANSITORY GASTROPLASTY PRE-SERVING DUODENAL BULB.F. Mittempergher, E. Di Betta, C. Casella, B. Salerni. Chair ofGeneral Surgery, University of Brescia, Italy
The aim of this study is to evaluate the results obtained usingtwo malabsorpitive procedures for severe obesity.A prospective randomised study was carried out from May 1999to May 2000. Twenty patients were operated on, 10 by theScopinaro’s biliopancreatic diversion (group A) and 10 by theBPD with transitory gastroplasty preserving the duodenal bulb(group B). Controls were carried out at set intervals (1, 3, 6, 12,18 months after operation) to evaluate weight loss and themetabolic effects of surgery in terms of glucose, iron, calciumand protein status.
Age, body mass index and percentage of excess body weightwere similar in both groups. In the group A the weight lossexpressed as percentage of excess body weight (EW%L) was28.4% ± 3.7%, 40.6% ± 5.2% and 50.5% ± 8.2% respectively 3,6 and 12 months after the operation. In the group B the EW%Lwas 38.6% ± 5.3%, 51.0% ± 4.2% and 65.8 ± 1.1% respectively3, 6 and 12 months after the operation.The difference was notstatistically significative.There was no hospital mortality in bothgroups.Major complications did not occure in the group A, whilein 1 patient in the group B (leakage of the gastric band).Although we did not observe any major plasmatic reductions ofalbumine, iron and calcium in both groups, patients in group Bhad major concentrations of albumine and iron than the otherones (p>0.05).
Our results showed that both techniques are valid solutionsfor the treatment of morbid obesity.The relatively more invasivenature of the BPD with transitory gastroplasty preserving duo-denal bulb makes, in our opinion, the Scopinaro’s BPD the firstsurgical approach for severe obesity. Nevertheless, the BPDpreserving duodenal bulb could be a good choice in casesalready treated by a gastro-restrictive operation with unsatisfac-tory result.
70. COMPARISON OF MICRONUTRIENT DEFICIENCIESAFTER ROUX-Y GASTRIC BYPASS AND BILIOPANCRE-ATIC DIVERSION WITH ROUX-EN-Y GASTRIC BYPASS INMORBID OBESITY.Skroubis George*, Sakellaropoulos George**, Mead Nancy *,Nikiphoridis George**, Kalfarentzos Fotis*. Nutrition Supportand Morbid Obesity Clinic, Surgical Department* andDepartment of Medical Physics**, School of Medicine,University of Patras, Greece
Background: Patients who underwent either Roux-Y gastricbypass (RYGBP) or biliopancreatic diversion with Roux-Y gas-tric bypass (BPD with RYGBP) are at risk of developing meta-bolic sequelae as a consequence of malabsorption.The aim ofthis study is to compare the potential differences in micronutri-ent deficiencies between these two types of bariatric operations.
Methods: This is a retrospective analysis of a prospectivedatabase. From June 1994 to April 2001, 196 morbidly obesepatients underwent various bariatric procedures at our institu-tion. Of these patients, 78 (mean BMI 45.7, SD=4.8) who under-went RYGBP (gastric pouch 15 ± 5ml, alimentary limb 80-100cm, cholopancreatic limb 60-80cm), and 60(mean BMI 56.6,SD=6.2) who underwent BPD with RYGBP (gastric pouch 15 ±5ml, alimentary limb 350cm with common limb 100cm), wereselected and studied for the incidence of micronutrient deficien-cies at 1, 2 and 3 years postoperatively. After surgery, all
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patients received a multivitamin and mineral supplement daily.Oral calcium supplementation was administered at a dose of1gr/day in RYGBP patients and 2gr/day in BPD with RYGBPpatients. An oral iron supplement was prescribed only for pre-menopausal women at a dose of 80mg/day, independently ofthe type of operation. Starting at 6 months postoperatively, vita-min B12 supplementation was given IM at a dose of 1000-3000mg, depending on measured values. A variety of nutritionalparameters including Ht, Hb, Fe, ferritin, folic acid, vitamin B12,calcium and phosphorus, were measured preoperatively andpostoperatively at 1, 3, 6, 12, 18 (BPD with RYGBP pts) and 24months, and yearly thereafter.
Results: The nutritional parameters investigated are shown inthe table below:
Type of OperationRYGBP BPD with RYGBPof pts/no of points/no.
with deficiency/ of points with deficiency% points with deficiency % points with deficiency
Normal values: Hb: men>13.5g/dl-women>12.5g/dl, Fe:>50mg%,Ferritin:>9ng/ml, Folic Acid:>1.5ng/ml, B12:>200pg/dl. Ca:>8.5mg/dl,
P:>2.5mg/dl.Values of the nutritional parameters were compared at simi-
lar periods postoperatively between the two groups. No statisti-cal difference (p<0.05) was observed between the groups forany of the nutritional parameters studied. All the micronutrientdeficiencies were mild, without clinical symptomatology andwere easily corrected with additional supplements of the defi-cient micronutrient with no need for hospitalization.
Conclusion: There was no statistical difference in themicronutrient parameters studied following RYGBP vs. BPDwith RYGBP. The most common deficiencies encountered wereof iron and vitamin B12. The incidence of Ca deficiency wasessentially nonexistent, and no deficiencies of phosphorus orfolic acid were observed.
71. JEJUNOILEAL BYPASS – STATUS 25 YEARS AFTERTHE OPERATION.Villy Våge1, Jan Helge Solhaug2, Asgaut Viste3, Arnold Berstad4
Department of Surgery, Førde1, Deakon Hospital, Oslo2,Department of Surgery3 and Department of Medicine4,Haukeland University Hospital, Bergen, Norway
Background: Jejunoileal (JI) bypass with ileocolostomy orileojejunostomy was a widely performed procedure for morbidobesity in the 1970’s. The operation leads to intestinal malab-sorption and was effective in reducing weight but was aban-doned due to its side effects. The purpose of this study was toevaluate the long-term results following JI bypass at aNorwegian University Hospital.
Method: From november 1971 until september 1976 a total of36 patients were operated. Median age at operation was 33years, median BMI 42 kg/m2. Shunt lengths varied between 45and 60 centimeters.Vitamin and mineral supplements were not
prescribed as a routine. At the present check-up during year2000, all 28 patients still alive (eight patients were dead) had aclinical examination and biochemical tests. Twenty-one of 23patients with a functional shunt had bone density measured and15 patients agreed to collect feces for measurement of fecal fat.
Results: Ten of 36 patients (28 %) had had their shuntreversed.With one exception all these patients quickly regainedweight, and five of them (50 %) are dead. Causes of death were;cardiac failure (2), septicemia (1), suicide (1), cerebral bleeding(1). At death three of the five patients (60 %) were on treatmentfor diabetes mellitus and hypertension.
23 patients with an intact JI shunt were alive, but five of them(22 %) had had the shunt shortened due to weight gain. Afterreaching stability the weight loss has been maintained. Despitea median age of 56 years (range 48 – 80) none of the patientswith an intact JI shunt have developed coronary heart diseaseand none were on treatment for diabetes mellitus.Malabsorbtion of fat is still present. Blind loop syndrome, flatu-lence, foul fecal smell and diarrhoea are the most troublesomelong term sequela. Deficiencies in vitamin D, vitamin E,Calcium, Magnesium and Zinc are common, and 48 % receivedvitamin B12 supplement. Two of 21 patients (age 80 and 57years) had osteoporosis.Three patients with an intact JI shunthad died and the causes of death were; Intestinal ischemia (1),alcoholic hepatitis (1), carcinoma of the pancreas (1).
Conclusion: When the optimal length of shunt is found, JIbypass maintains a significantly reduced weight for 25 years.Vitamin and mineral deficiencies are common, but no seriousclinical deficiency states are seen.
72. IMPROVEMENT IN INSULIN LEVELS AND INSULINRESISTANCE AFTER BILIOPANCREATIC DIVERSION INMORBID OBESITY WITH AND WITHOUT DIABETES TYPE II.Maria Laura Cossu, Enrico Fais, Matteo Ruggiu, ClaudioSparta, France Cossu, Giuseppe Noya. Department of emer-gency surgery – University of Sassari, Italy
Background: The purpose of our study was to determine theactual metabolic effects of biliopancreatic diversion, particularlyof the diversion itself, on glyco-lipid metabolism and expeciallyon insulin resistance and insulinemia levels, in morbid obesitywith and without diabetes II.
Method: Since 1998 three groups of patients, 22 with morbidobesity without diabetes II, 26 with morbid obesity and diabetesII, and 19 with slight obesity and diabetes II, have been treated.They were submitted to pre and postoperative assays of fastingglycemia and insulinemia, and an assay of the lipidic parame-ters. In the first group of patients who were without diabetes IIor IGT and had a normal fasting glycemia, the mean preopera-tive was BMI 49.66; we performed the classic biliopancreaticdiversion. In the second group , the mean preoperative BMI was53.19; 21 patients had diabetes II and 5 had IGT.We performedthe original biliopancreatic diversion also in these patients. Inthe last group the mean preoperative BMI was 34.15:16 patientshad diabetes type 2 and 3 patients had IGT; 13 patients were intreatment with tablets and/or insulin. In this group we performedthe biliopancreatic diversion without gastric resection and withthe pylorus preserving technique.
Results: The results regarding the glycolipidic and insuline-mia metabolism in the groups of patients were very satisfactory,as summarized in the following table:1) BPD with gastric resection on 22 patients without diabetes 2
PREOPERATIVE 6 MONTHS PBMI 49.66 35.37
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Glycemia 90.5±2.39 77.1±2.04 <0.001Isulinemia 26.81±5 10 8.48±4.45 0.02452) Classic BPD on 26 patients with diabetes II
PREOPERATIVE 6 MONTHS PBMI 53.19 39.08Glycemia 138.2±11 84.2±2 <0.001Insulinemia 23.70±3.6 9.87±1.89 0.0023) BPD without gastric resection on 19 patients with diabetes II
PREOPERATIVE 6 MONTHS PBMI 34.15 28.1Glycemia 153±17 98.4±4.1 0.0128Insulinemia 28.35±2 10.8±1.3 <0.001Comparative Analysis:Preop. glycemia p:0.0008 group 1 vs group 2 and 36 months Glycemia p: 0.03 group 2 vs group 3Preop. Insulinemia p:no statistical difference in thegropus6 months Insulinemia p: no statistical difference in the groups
Conclusion: The comparative analysis of global values indi-cates that biliopancreatic diversion without gastric resection hasthe same beneficial effects in glycolipidic and isulinemia metab-olism and suggested that this improvement is due to the bil-iopancreatic diversion . The duodenal switch technique seemsto be a surgical option in cases of slight obesity associated withserious glyco-lipid alterations.
73. CHOICE OF OPTIMAL BARIATRIC PROCEDURE INTHE TREATMENT OF MORBID OBESITY.A. S. Lavryk, V. F. Sayenko, O. S. Tyvonchuk, O. P.Stetsenko, T.V. Masurak. Institute of Surgery & Transplantology, Kyiv, Ukraine
Background: The problem of morbid obesity (MO) can bedecide by surgery only . There is no ideal operation for morbidobesity and there probably never will be one.We present resultsof the surgical treatment of MO over the last 18 years, including:jejunoileal bypass(JIB), various gastric restriction procedures,intragastric balloon, distal gastric bypass, biliopancreatic diver-sion (Scopinario).We can divide our experience on two periods.
Methods: First period: from 1983 till 1997, when we did 64 JIBin various variants – by Scott – 3, by Buchwald – 8, by Payne-De’Wind –15, by our method – 38; 1 gastric bypass by Griffen;34 – nonadjustable gastric banding (NAGB) by Wilkinson –Peloso and 2 VBG. In this group mean weight of the patientswas 210kg (160 ± 290), BMI > 55 kg/m2, mean age 36.5 (18 –55). Second period was opened from 1997 we performed 41gastric banding(GB): 8 – adjustable (Lap Band BioEnterics), 33– nonadjustable (Kuzmak – small pouch). Mean age was 35 (.Mean weight was 158 (95 – 223) kgs. BMI was 53.6 kg/m2 aver-age. BioEnterics Intragastric balloon (BIB) was implanted in 8patients (2 males and 6 females) . Mean age was 38 (35 – 45)years, mean weight was 169 kg. (95 – 220) mean BMI was 52kg/m2 (35 – 70). In 3 patients with BMI > 55 kg/m2, age 30 to 37years (2 females and 1 males) distal Roux –en- Y gastric bypass(RYGBP) were performed. In 2 patients were performed Woodmodification (Total length of limb - 400 cm, common of limb -200 cm), and in 1 – Torres and Oca “for sweet eaters“ modifica-tion (Total length of limb - 245 cm, common of limb - 152 cm).In2 females (BMI > 55 kg/m2 ) – BPD Scopinaro
Results: In the group with JIB was significant weight loss, withan average of 62±17 kg lost in 24 months following surgery.High amount of postoperative complications (bypass-enteritis24.3%, excessive malabsorption 18.3%, renal stones 2.2%, andgall stones 2.2%, metabolic disorders – 1.28%) make refused ofthis operation. GB showed acceptable weight loss results. In
long term period after NAGB) by Wilkinson – Peloso increaseweight in consequence of excessive restriction of proximalpouch of the stomach occur. GB with proximal pouch 20 – 30 mlgive weight loss 35 – 43% except “sweet-eaters syndrome”patients, but lipid profile decreased inadequate. Mean weightloss in patient with BIB was 19.5 kg (12-28), 1 case of balloonintolerance and 1 unsatisfactory case occured. After BPD andRYGBP in 3 month weight loss was 21.5 ± 3.8 (14.8%) and 28± 2.9 (16%) with normalization of the blood lipid values.
Conclusion: Gastric banding – effective and safe weightreduce method in patient with BMI <50 kg/m2 without consider-able hyperlipidemia.The optimal method in patients with supermorbid obesity and sweet-eaters syndrome – gastric bypass orBPD Scopinaro method. Intragastral balloons are effective inpatients with initial form morbid obesity and in patients withsuper obesity for preoperative preparation.
74. EARLY EXPERIENCE WITH LAPAROSCOPIC BIL-IOPANCREATIC DIVERSION (LBPD).Roberto M. Tacchino, Maurizio Foco, Gianni Greco, MarcoCastagneto. Department of Surgery, Catholic University SH,Rome, Italy
Background: Biliopancreatic diversion is a well-establishedprocedure with excellent weight loss and long term results.Laparoscopic approach has been used successfully for manybariatric procedures and proved to be safe and effective inreducing postoperative morbidity. Biliopancreatic diversion is awell-established open procedure that ensures excellent weightloss. Recently a laparoscopic BPD with duodenal switch hasbeen successfully performed.We report our early experience oflaparoscopic BPD with gastric resection (Scopinaro procedure).Development of a laparoscopic technique allows the same oper-ation without abdominal incision and lower postoperative dis-ability.
Methods: The operation is performed with five lap ports.Gastro-epiploic vessels, right and left gastric artery are coagu-lated and divided. Duodenum and stomach are sectioned bythree to four applications of linear stapler. We then proceed tothe identification of the ileocecal valve. Measurement of theileum is made against a calibrated clinch in steps of five cm withthe small bowel fully stretched. The 50 and 250 cm points areidentified and marked. Section of the ileum and mesentery ismade by linear stapler. Ileoileal anastomosis is made side toside with linear stapler. Dissection through the mesocolon closeto the Treitz is the next step and the alimentary limb is broughtup to the gastric stump.The gastro-entero anastomosis is com-pleted with a 60mm linear stapler. In order to avoid increasedrisk due to excessive operative time, we imposed a time limit offour hours, after which the procedure was converted to an openone. Fourty consecutive patients underwent laparoscopic BPDform April to March 2001.
Results Twentyfive patients were completed laparoscopically.The conversions were always due to time limit. One patient wascomplicated by an anastomotic leak requiring reoperation.Earlycase results show no perioperative mortality, acceptable mor-bidity and weight loss comparable to open cases.
Conclusions: This very complex advanced laparoscopic pro-cedure still needs improvement of technical details.Laparoscopic biliopancreatic diversion is a feasible alternativeto the open operative procedure.
75. LAPAROSCOPIC BILIOPANCREACTIC DIVERSION –TECHNIQUE AND INITIAL RESULTS.
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Dyker Paiva, MD, Lucineia Bernardes, MD; Livio Suretti, MD.Surgical Department - Mater Dei Hospital, Belo Horizonte,Brazil
Background: Bilio-pancreactic diversion (BPD), idealized byScopinaro, is a method provenly efficient in treating morbid obe-sity. Using the laparoscopic technique, it is possible to reducethe number of complications related to conventional surgery,such as in-hospital time, respiratory complications, early returnto work and incisional hernia.
Methods: From July 2000 to April 2001, 40 patients were sub-mitted to laparoscopic BPD: 29 women and 11 men, with anaverage age of 39 (range = 17 to 60). Average IMC = 43.6kg/m2. The employed technique strictly followed the original,with the following stages: (1) cholycestectomy;(2) large skeleti-zation, gastric curvature, and duodenal section 2 cm below thepylorus; (3) skeletization of the small gastric curvature; (4) gas-tric section; (5) measurement of the small bowel as of the cec-cum; (6) ileoentero anastomosis at 50 cm of the ileo-ceccalvalve; (7) passage of the alimentary limb through the meso-colon; (8) 35 mm linear gastroentero anastomosis. All of theseprocedures will be presented on video. Seven of these patientswere submitted to the removal of the adjustable gastric bandingand converted to BPD. All were submitted to a cholecystectomy;one patient was submitted to an umbilical hernioplasty. Follow-up is still in progress. Patients are seen at the clinic monthly upto the sixth month and, subsequently, every three months, withblood tests every three months.
Results: All surgeries were carried out successfully throughlaparoscopy. Excess weight loss was 91% in four patients whoare in the tenth post-operatory month, 75% in two patients in theeighth month, and 48% in three patients in the sixth month.Mortality was 2.5% (one patient in the fifth day after surgery,due to massive pulmonary emboly).The average operation timewas 210 minutes (range: 130 to 480), and the average length ofhospital stay was 4.3 days (range: 3 to 21).There were five spe-cific post-operatory complications (12.5%): two pulmonaryembolies; 2 bleedings in the staple line; one fistula. Later com-plications totaled six (15%): 3 (7.5%) cases of diarrhea up to thefourth month, 2 cases (5%) of elevated PTH and normal cal-cium, and one (2.5%) case of hypothyroidism that was difficultto control clinically.
Conclusion: BPD may be executed through laparoscopy with-out changes in the original technique, increase in risks or com-plications and without jeopardizing results.
76. LAPAROSCOPIC SCOPINARO WITH DUODENALSWITCH AND ASSOCIATED CRURAL REPAIR AND CHOLE-CYSTECTOMY.George A Fielding. Wesley Hospital and Royal BrisbaneHospital, Brisbane, Australia
The duodenal switch variation of the Scopinaro bypass hasgained some favour. Certainly with laparoscopic application it istechnically easier than a standard Scopinaro which involved adistal gastrectomy. It has the added advantage of maintenanceof the antrum and first part of the duodenum with pylorus.
The video shows a technique for duodenal switch with gastricsleeve resection using a standard Scopinaro 50cm commonchannel and 200cm roux limb. It also shows a side to side sta-pled anastomosis between the first part of the duodenum andthe roux limb.This is the author’s preferred technique and is dif-ferent to what has previously been described for this procedure.The previous descriptions have involved use of a trans-oral pas-sage of an EEA anvil and trans-abdominal insertion of an EEA
gun. Technique shown here is a completely laparoscopic intra-abdominal procedure which avoids sending trans-oral instru-mentation and eliminates the need to insert the EEA gunthrough the abdominal wall with problems with gas leak andwound sepsis.
The patient in this video also had a symptomatic hiatus her-nia which was treated by reduction of the hernia and a cruralrepair. A cholecystectomy is performed as part of the Scopinaroprocedure.
The author has performed one hundred and three laparo-scopic Scopinaro bypasses, twenty-seven standard and sev-enty-six with sleeve and duodenal switch as shown here.
77. LAPAROSCOPIC DUODENAL SWITCH: TECHNICALASPECTS.A. Baltasar, R. Bou, J. Miró, M. Bengochea, N. Pérez. Hospital“Virgen de los Lirios”, ALCOY. Alicante. Spain.
Background: The Duodenal Switch is a variation of the bilio-pancreatic diversion surgery for obesity. Vertical subtotal gas-trectomy, division of the duodenum and BPD is done with aCommon loop of 75 cm, Digestive loop of 250 cm and 250 cmof bypassed proximal small bowel. Open surgery was done untilrecently. The laparoscopic technique is presented in video.
Methods: Twelve patients have been operated on by thelaparoscopic aproach. Six trocars are used. Devascularizationof the greater curvature of the stomach and proximal duodenumis done with the harmonic scalpel.The duodenum and the stom-ach resection are done with linear staplers.The variation in thetechnique compared with the open method have been the ante-rocolic position of the digestive loop. The end-to-side duodeno-ileal anastomosis is hand-sutured. The side-to-side entero-enterostomy of the digestive and biliopancreatic loops is donewith a linear stapler and the enterostomies closed by hand-suture.The mesenteric defects are not closed.
Results: Operating times ranged from 3:15 to 5:30 hours.One patient required 5 units of pack cells due to bleeding of thevertical subtotal gastrectomy staples line even after a serosa-serosa hemostatic continous suture line. One case was con-verted due to stapler failure. Postoperative stay was 4 - 9 days(mean 5).
Conclusions: The Duodenal Switch can be done laparoscop-ically with the same principles as in the open method. Althoughthe operative times are longer the technique seems suitable asan alternative.
78. SWEDISH ADJUSTABLE GASTRIC BAND (SET PAT-TERN).Antelmo Sasso Fin. Hospital São Luiz, Brazil
The band will be better placed if you put it below the lowestpoint of the right diaphragmatic pillar and above the left gastricartery tunneling carefully through the connective tissue behindthe retoperitoneal part of stomach coming through the gas-trophrenic ligament.Do not dissect through the phrenic aponeu-rosis because sometimes it is difficult prenetrate.
The position of the flaps of the band may be on the left sideor right side without affecting the results. The operator shouldchoose the location must convenient for him based on theanatomy, taking care not to leave enough of the stomach wallfree to permit slippage to occur; remembering that later theentire anterior transverse diameter of the stomach must be usedto establish the tunnel and that the wall should only approximatethe band loosely allowing only enough space to accommodateinflation of the band without traction on the stomach covering
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the band.This consideration avoids erosion of the stomach wallwhen the band is maximally inflated (9ml).
Over the last 25 years the biliopancreatic diversion has beensuccessfully used as one of many surgical treatments toachieve significant long term weight loss. However, this proce-dure was not free of post operative complications.We think thatusing a mini-invasive approach a big incision is spared, result-ing in a faster recovery time with less pain and prompt ambula-tion. Our procedure is a modification of the technique describedby Scopinaro and it consists of a distal gastrectomy with a longRoux-en-Y reconstruction (Video presentation). Patient in thesupine position with head-up tilt with the surgeon operatingbetween the legs of the patient. The main monitor should go atthe head of the table.The laparoscope is first placed through anumbilical port (10 mm) and initial inspection of the peritonealcavity performed. We favors a 30-degree forward-oblique view-ing laparoscope Two additional left upper quadrant trocars (12mm) and a right upper quadrant trocar (12 mm) are placedunder direct vision.
The site of incision is determined at the greater curvature.Then we begin mobilizing the greater curvature and continuethe mobilization toward the duodenum. This detachmentrequires traction of the stomach by an atraumatic grasper by theassistant and is performed with the harmonic scalpel.Next passa grasper along the posterior aspect of the stomach and thenthrough an avascular window in the lesser omentum. At thattime, we divide the duodenum with an Endo GIA stapler, 45 mmlong with 3,5 mm staples well beyond the pylorus. Carefullyinspect the staple line and reinforce it with interrupted sutureswhen necessary. Select the proximal transection site.The EndoGIA stapler, 45 mm long with 3,5 mm staples is then fired threetimes as shown horizontaly.In addition the coronary vessels arealso divided with a Endo GIA II stapler, but this time using thevascular load (45 mm length, 2.0 mm staples).In order to create the Roux-limb, the jejunum is divided 50 cmbeyond the ligament of Treitz by using an Endo GIA, 45 mm longwith 3.5 mm staples. In addition the mesentery is divided with aharmonic scalpel.
A retrogastric-retrocolic tunnel is performed in the mesocolonanterior and lateral to the ligament of Treitz. This "window" willfacilitate the passage of the Roux-limb.The Roux-limb is measured from caecum to 50 cm in ileonlength. An side-to-side anastomosis between the proximaljejunum and the Roux-limb is created by firing a Endo GIA II sta-plers. The enterotomy is closed using another load of staples.The Roux-limb is now advanced trough the mesocolic window(retrocolic) near the transected stomach when is fixed with inter-rupted sutures. Following an enterotomy an anastomosisbetween the gastric pouch and the Roux-limb is created by fir-ing a Endo GIA II. The enterotomy is stapled shut with anotherload of Endo GIA II.Finally we remove the specimen through umbilical port.
80. THE PARS FLACCIDA TECHNIQUE IN LASGB-OPERA-TION WITH NEW 11CM LAP-BAND®.Ralph Peterli, Peter Tondelli. Surgical Clinic, St. ClaraspitalBasel, Switzerland
Background: The slippage rate of the perigastric approach in
the laparoscopic adjustable gastric banding operation (LASGB)with the 9.75 or 10 cm LAP-BAND® (Bioenterics, Carpinteria,Ca, USA) was approximately 10%. Changing the operationtechnique to include the fatty tissue of the lesser curvaturewithin the band, the so-called pars flaccida technique, led to areduction in the slippage rate to almost 0%. For this purpose thelength of the band had to be increased to 11cm. The volume ofthe circumferential inflation membrane on the inner surface ofthe band is now 9cc instead of 4 cc for more convenient adjust-ment of the stoma diameter.
Methods: The video describes the operation technique of thenew 11cm LAP-BAND® applied at our institution including posi-tioning of the patient, trocart placement, the use of liver retrac-tion hook and abdominal wall suspension device.
81. GASTRIC POUCH DILATION FOLLOWING LAGB SYS-TEM PROCEDURE: THE ITALIAN EXPERIENCE.L. Angrisani, F. Furbetta, S. B. Doldi, N. Basso, M. Lucchese, M.Giacomelli, M. Zappa, E. Lattuada, L. Di Cosmo, A. Veneziani,G. U. Turicchia, F. Favretti, M. Alkilani, P. Forestieri, G. Lesti, F.Puglisi, M. Toppino, F. Campanile, F. D. Capizzi, C. D’Atri, L.Scipioni, C. Giardiello, N. Di Lorenzo, S. Lacitignola, M.Belvederesi, B. Marzano, G. Bernante, A. Luppa, V. Borrelli, M.Lorenzo. Italian Group for Lap Band, GILB, Naples, Italy
Background: Gastric Pouch Dilation (GPD) is the most fre-quent complication of Laparoscopic Adjustable Gastric Banding(LAGB) System procedure.
Methods: Patients suffering one or more episodes of GPDhave been selected from the data registry of the Italian Groupfor LAP-BAND (GILB), which collect patient’s data from January‘96. Peri-gastric dissection with 9.75cm band was always per-formed. Intra-operative pouch calibration varied between cen-tres.
Results: Data from 28 centres with different level of experi-ence (minimum 11, maximum 411 Pts) were available. 89(6.2%) out of 1437 LAGB‚ operated pts. developed a gastricpouch dilation: 71, 14, and 4 pts. presented one, two or threeepisodes respectively. 33 (37.1%) pts. were without symptoms.In the remaining, the most common clinical presentation wasvomiting (n=31; 34.8%). Diagnosis was made by Rx bariummeal or gastrographin in all but two pts. Conservative treatmentwith band deflation was performed in 42/89 (47.2%) pts.Surgical treatment under general anesthesia was performed in47/89 (52.8%;) pts; 3.8% of 1437 operated cases. Laparoscopicaccess was preferred for: debanding (n=19; 40.5%) and bandrepositioning (n=26; 55.3%) while gastric bypass (n=1; 2.1%)and oesophagojejunostomy (n=1; 2.1%) were performedlaparotomically. Considering the sequential number of patientsoperated per centres which have developed GPD: 57/89 Ptswere observed within the first 50 operated cases, 19 Pts wererecorded between cases 51-100, 8 between cases 101-150, 2and 1 patient between cases 151-200 and 201-250 respectively.
Conclusion: The learning Curve in terms of surgical tech-nique and patient management play a fundamental role inreducing the incidence of Gastric Pouch Dilation followingLAGB.
82. LONG-TERM RESULTS OF LAPAROSCOPIC ADJUST-ABLE GASTRIC BANDING IN THREE MAJOR CENTRES INBELGIUM.M. Belachew*, C. Desaive**, P. Belva***. *Chr Huy, **Chu Liege,***Chu Charleroi, Belgium
Background: The authors will present long term results of
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Laparoscopic Adjustable Gastric Banding (LAGB%) for thetreatment of morbid obesity.
Material and Methods: 763 underwent LAGB operation in 3major surgical centres in Belgium, sharing the same criteria forpatient selection and the same surgical protocol standardizedafter the learning curve (i.e. virtual pouch, 3-4 anterior gastro-gastric sutures and band left empty). Sex ratio: 22% M / 78% F;Mean age: 34yrs; Mean BMI: 42kg/m2 (35-65). Data regardingcomplications, reoperations and BMI evolution were collectedduring a follow-up period of minimum 4 years. Risk of stomachslippage and pouch dilatation in relation to time was also statis-tically evaluated (Kaplan- Meyer curve).
Results: Mean BMI drops to 30kg/m2 during the first 24months. After this period, there is a moderate weight gain butBMI stabilizes after 4 years at around 30 kg/m2. Few peri-oper-ative complications were observed: Gastric perforation (4),bleeding (1), colonic perforation (1). Conversion rate: 1.3%. Latecomplication: No trocar site hernia. Total and irreversible foodintolerance due to stomach slippage was observed in 59 cases(8%). Gastric erosion was detected in 7 patients (1%). Accessport problems ( tilting of the port, broken tubing, port infection)occurred in 20 cases (3%). Risk of slippage decreases with timeand gets stabilized at 30 % (of all slippage) at 54 months. Re-operation: Band removal: 24(3.3%); Band replacement: 2(0.3%); Open re-positioning: 9 (1.7%); Laparoscopic re-posi-tioning: 45 (6%).
Conclusion: After the leaning curve which ended at the begin-ning of 1995, we think that the problems related to surgical tech-nique have been solved. Material has also improved (injectionport). The complication rate is stable and acceptable. Stomaadjustment remains possible and useful even after years.Patient selection, good follow-up and multi-disciplinaryapproach are mandatory for the future of the procedure.
83. LAP-BAND, PREVENTION OF SLIPPAGE: SERIES OF1410 PATIENTS: SWITCHING FROM THE 9.5/10.0 BAND TOTHE NEW GENERATION 11.0 BAND.Jean-Marie Zimmermann, Michel Blanc, Pierre Mashoyan, ÉrickZimermann, Jean-Marc Grimaldi. Clairval Private HospitalCenter, Marseille, France
The authors present a review of their LAP-BAND System(LAGB) experience, commencing in July 1995. From July 1995through April 2001, 1316 patients underwent surgery. Theseries meets the same criteria as the series in the literature:mean age 41 years (17- 65), mean BMI 43 kg/m2 (35-80), meanweight 114 kg (83-230), mean excess weight 43 kg, 85%women to 15% men, and 174 patients with a BMI greater than50 (14.1%).The materials used were 1090 LAGB (original ‘peri-gastric’ technique), 103 LAGB (‘pars flaccida’ technique), 12311.0cm LAGB (‘pars flaccida’ technique).
Slippage has been reported more frequently (up to 18% inthe literature) with the LAGB, contrarily to the SAGB. Thisoccurred 129 times with the LAGB using the original techniqueon 1090 patients, i.e., 11%, including seven cases with repeatedslippage. With the Swedish band, there are two significant dif-ferences: the position in contact with the diaphragm and not withthe stomach, and a wider balloon that consequently com-presses a greater width.
Migration is most frequent (up to 4.6% in the literature) withthe SAGB. This band has a balloon that rolls up in the event of“overinflation,” and allows the sharp edge of the band to comein contact with the visceral layer, creating a point of friction,whence the possibility of erosion.To palliate these problems, the
authors recommend taking two steps:- Firstly, placing the 10.0cm LAGB in the pars flaccida position.There was no slippage in 103 patients who underwent surgerybetween January 2000 and September 14, 2000 (Twenty-sevenrepositioning procedures were necessary during the same post-surgical period with the original technique and the 9.5cm band).-Secondly, placing an 11.0cm LAGB with a wider balloon thatcannot roll up, in the pars flaccida position, in order to preventslippage without risk of migration.This band is the new genera-tion LAGB. To date, from September 15, 2000 through April 15,2001, of the 123 bands that have been placed, no early dilata-tion has occurred. Three early cases of major dysphagia inpatients with pre-operative esophagitis have led to reoperation,but this has been prevented in subsequent cases by pre-opera-tive medication of patients with GERD.
In this way, the authors hope to contribute to improving theresults with the laparoscopic gastric banding technique, which,despite its drawbacks, still remains an effective, least aggres-sive and most easily reversible technique for the surgical treat-ment of morbid obesity.
84. LATE OUTCOME OF ADJUSTABLE GASTRIC BAND-ING FOR SURGICAL TREATMENT OF MORBID OBESITY.Cornelius Doherty, MD, FACS, James W. Maher, MD, FACS,Debra Heitshusen, RN, BSN. Department of Surgery, School ofMedicine, University of Iowa, Iowa City, Iowa, U.S.A.
Background: This prospective study reports long term, (>7years), follow up of patients who had adjustable silicone gastricbanding, ASGB, for treatment of morbid obesity.
Methods: Subjects were 45 kg or more overweight and hadno prior history of surgical treatment of their obesity. All had ahistory of being obese 5 years or more and had failed to sustainweight loss with calorie restriction and behavior modificationprograms. The adjustable gastric band was placed at laparo-tomy around the fundus and tightened to create an outlet chan-nel of 12 mm and a proximal pouch of 25 ml. Subjects werewithdrawn from the study, if the band was removed, or if theyrequested withdrawal at any time.
Results: Between March 17, 1992 and may 1, 1995, 26females and 14 males entered the study. Mean age was 34years, (range 19-51 years). Mean height was 171 centimeters,(range 152-190 cms). Mean weight was 147 kilograms, (range100-214 kgs). Mean Body Mass Index was 50, (range 39-75).There was no operative mortality. Mean Body Mass Index andMean Percentage Excess Weight Loss were reported only forsubjects with an intact functioning adjustable gastric band sys-tem. Post operative mean Body Mass Index at 1 year one was39, 2 years 38, 3 years 32.8, 4 years 36.5, 5 years 40.6, 6 years44.3, 7 years 39.6, 8 years 44.1. Post operative mean % ExcessWeight Loss at 1 year was 44%, 2 Years 47%, 3 years 32.8%, 4years 39.8%, 5 years 30.3%, 6 years 31.8%, 7 years, 33.1%, 8years 32%. Twenty-one intraabdominal reoperations were nec-essary to correct complications related to the implantedadjustable silicone gastric band. The problems were: 2.5%infected band, 5.0% obstructive aneurysmal deformity of theinflatable bladder segment of the band, 17.5% enlarged pouchwith obstructed outlet channel (mean time of occurrence 44months; range 21-88 months), 27.5% with herniation of the dis-tal stomach through the band into the posterior lesser sac caus-ing life-threatening obstruction (mean time of occurrence 32months; range 21-68 months. Twenty-two and a half percent ofsubjects have voluntarily withdrawn from the study. After 109months only 13 subjects remain in the study.
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Conclusion: Progressive loss in efficacy of the ability of theASGB to maintain a significant decrease in BMI was observedover the nine years of this study. The need for intraabdominalreoperation was 52.5%.These long term date fail to support theuse of ASGB for surgical treatment of morbid obesity.
85. EARLY RESULTS WITH THE HELIOGAST BAND.M. Vertruyen. Europe St-Michel Clinic, Brussels, Belgium
After a bariatric surgery experience of 543 patients using theLAPBAND system between october 93 and december 2000, theauthor decide to perform a consecutive serie of 30 patients withthe Heliogast band system between december 2000 and febru-ary 2001. The sex ratio was 26 females for 4 males and themean age was 38 years (range: 20-54). The mean body weightwas 112 kg (range: 93 -145) corresponding to o mean BMI of 44kg/m2 (range: 35-56). The author decide to change of bandingsystem for several reasons:The presence of an easy unlockablelocking system of the Heliogast band. The frequence (2.8 %) ofdisruption of the connecting tube of the Lap-Band. The smallerport size of the Heliogast band
In all the cases, the perigastric way was used and the proxi-mal pouch was calibrated with 15 cc of saline. A classical ante-rior fixation was performed with 4 sero-serous stiches. At theend of the procedure, 2 cc of saline were injected in the systemin order to secure the locking system.The mean operative timewas 45 minutes (range: 30-60). There were no conversions andno intraoperative complications.The mean hospitalisation staywas 1 day (0-2). As early complication, we observed 1 case(3.3%) of leakage of the band at the level of the locking system.This area is not reachable during placement of gastro-gastricsutures.
In 3 cases (9.9%), no efficient adjustement of the band waspossible even with injection of more than 10 cc of saline. A radi-ographic study showed the absence of reduction of the stomadiameter and confirmed an external distortion of the inflatablepart of the band.The 4 cases (13.3%) required reoperation andthe replacement of the initial band with the second generationof heliogast band (Medium size). All the reoperations were per-formed by laparoscopy and required an one-day hospitalisation.In a very short follow-up period, the 26 first patients required amean level of 7 cc (range: 6-9). The 4 patients requiring reoper-ation needed a mean of 3 cc (range: 2-3). The visual examina-tion of one and the ineffective bands showed the persistence ofa aneurysm hernia in the inflatable part of the band. Surgeonsneed technical advise about the soundness of a new device andsecurity about the quality control of the materials used beforeapplication of the new device. This serie is too small to give adefinitive conclusions but Helioscopie needs to solve as quicklyas possible the problems of size of the band, weakness andexternal distortion of the inflatable part.
86. LAPAROSCOPIC EXPERIENCE WITH A NEWADJUSTABLE GASTRIC BAND.Patrice Lointier, MD, PhD. Private Practice, Clermont-Ferrand,France.
Background: the purpose of this study is to present a prelim-inary laparoscopic experience with a new adjustable siliconeband named HELIOGAST.
Methods: since october 2000, 70 morbidly obese patientshaving body mass index (BMI) > 35kg/m2 underwent HELIO-GAST laparoscopic procedure.The product used possesses anopening and closing system. In the event of acomplication, the ring does not need to be cut and replaced by
another, but simply needs to be opened, repositioned andclosed as a simple procedure. This product is designed andmanufactured on the “one piece” principal which means that itdoes not have any mechanical weak point. The operative tech-nique is described in this video.The patient is placed in a mod-ified lithotomy position and reverse trendenburg (35°). Weemphasized the positioning of the patient which is the crux pointof the procedure. Initial access to the peritoneum was gainedthrough a working port. We used a 4 procare technique and 30°lens. We utilized the pars flaccida approach combined with apars condensa window to minimize risk of slippage. A 15 mlgastric pouch is created. Tunelling sutures on the anterior gas-tric wall prevent dislocation of the band and ensure that a pouchof correct size is created.Placement of the catheter and the portis discussed.
Results and Conclusions: this laparoscopic technique wassuccessfully completed in all patients even when hepatomegaly.This procedure has not been previously reported. HELIOGASTbanding (HB) in the short term at least is comparable to otherbands in effectiveness. HB has wide appeal since itsdemands less time and relative skill. However knowledge ofsubtle details and expertise is required to reproduce favorableoutcomes of permanent weight reduction and minimal compli-cations.
87. PACING THE STOMACH: OUR EXPERIENCE ON TWOOBESE PATIENT POPULATIONS.Cigaina V*., Saggioro A**. *Unit of Digestive SurgicalElectrophysiology O. C. “Umberto I” Mestre-Venezia, Italy**Digestive Diseases & Clinical Nutrition Departments O.C.“Umberto I” Hospital Mestre-Venezia, Italy
Background: After successful animal studies in 1992, the firsthuman implant of a gastric pacemaker to modify the gastricenvironment behavior and treat morbid obesity was performedin 1995. A cohort of 10 patients started to be followed with long-term data collected from 1998. A further group of 10 patientswere implanted during 2000. Purpose: Evaluate the safety (interms of reported complications) and effectiveness (in terms ofweight loss) of gastric stimulation in the morbidly obese popula-tion.
Methods: 20 subjects, between 41 and 69 of BMI, 4 malesand 16 females, age ranging between 23 to 62 years, wereimplanted with a second generation Implantable GastricStimulator (IGS™), Transcend ™, supplied by TransneuronixInc., New Jersey, USA. 13 of these subjects received a newpacer as a replacement for a previous device. The pacer wasplaced in the subcutaneous abdominal fat over the muscularfascia and connected to a bipolar lead, which was placed undergeneral anesthesia and by video-laparoscopy, in the lesser cur-vature of the gastric antral wall. The pacer was activated thirtydays after the implant. The patients were discouraged to drinkalcohol and sweet beverages. Monthly clinical controls wereobtained for the first 6 months period, and every three monthsthereafter.
Results: The first patient, of 1995 trial, lost 90% of her excessbody mass at 21 months after the implant. After pacer replace-ment she reached 60-70% of Excess Body Mass Loss (EBL)and maintained it till the 52nd month, when she had lead dis-lodgment.The results of all the patients, before having the firstpacer replacement, three months after, and the group implantedduring the 2000 are shown in the following table:
There have been no deaths or other major complications.Themain feeling reported from all the patient population during thegastric pacing was an early and increased satiety, which rein-forced the patients’ efforts for food intake reduction. Despite theelectrical stimulation of the stomach, no peptic related disordersor gastrointestinal side effects were reported. GERD wasimproved after stimulation. There have been 6 intra-operativegastric penetrations, as noted on operative gastroscopy withoutany clinical sequellae.Of the 13 replacements, six had lead dis-lodgments (two partial, four total), which occurred between thefirst and fourth months. This was probably due to inadequatetine length on the leads. Subsequently, after those events, allleads were fixed using sutures and only one partial dislocationwas reported.
Conclusions: Long-term studies continue to show that gastricpacing can be a safe and effective procedure. A metabolicchange or a new standpoint in the brain-gut axis is hypothe-sized, and studies regarding mechanisms of weight loss due togastric pacing are progressing.
88. IMPLANTABLE GASTRIC STIMULATION: PRELIMI-NARY RESULTS IN FRANCE.Jerome Dargent, MD. Polyclinique de Rillieux. Private practice,France
Background: A new technique has been added to bariatricsurgery: the Implantable Gastric Stimulation (IGSTM), whichseems to be able to induce satiety while avoiding the drawbacksof malabsorptive or restrictive techniques.An experimental pro-tocol was initiated by Transneuronix Inc., Mt. Arlington, NJ, USA,on the basis of Dr V Cigaina’s works, consisting of clinical trialslaunched in Europe and in the US at the beginning of year 2000.After approval by the ethics committee, the French centre ofexperimentation was located in Lyon.
Methods: The device (TranscendTM) consists of a stimulationlead implanted in the gastric wall and connected to an electricpulse generator implanted subcutaneously. The procedure isperformed through laparoscopy, using a wall suspensor. Thepossibility of a gastric perforation is checked during an intra-operative endoscopy. The authors present the surgical tech-nique and preliminary results obtained in France in 12 patients(5M, 7F) operated between July 2000 and February 2001.Meanage was 40,6 (31-51). Mean weight was 122.2 kg (93-146),mean BMI was 42.7 (39.1-48.6), and mean excess-weight 60 kg(42-74). 5 patients had comorbidities. 6 patients had the leadimplanted in a low position, six in a high position. The experi-ment was not randomised. Patients enrolled at the French sitewere also programmed to “high” output settings (10 mA pulseamplitude) at one month-visit.Patients were seen monthly post-implant.
Results: Postoperative course was uneventful in all cases. In2 patients, the lead was replaced because of dislodgement.At 6 months, mean excess weight-loss has been 8.5 kg (0-32)or 15% (0-51) of the excess-weight at the implant time.
Conclusion: The surgical procedure has to be standardizedfurthermore. A long-term follow-up will be needed in order to
assess the results with regard to weight-loss.The IGS could bealso an interesting second-step procedure in treating failures ofrestrictive procedures.
89. SUCCESSFUL USE OF ENDOSCOPIC ULTRASOUND(EU) TO VERIFY LEAD PLACEMENT FOR THEIMPLANTABLE GASTRIC STIMULATOR (IGS™).Scott A. Shikora, MD, Tamsin A. Knox, MD, Laurence Bailen,MD, Frederick J. Doherty, MD, Christa M. Trigilio, PA-C. NewEngland Medical Center, Boston, MA, USA
Background: Gastric stimulation is a promising new modalityfor achieving weight loss. The IGS, a pacemaker-like device(TranscendTM, manufactured by Transneuronix, Inc, Mt.Arlington, NJ), had been shown to be safe and effective for ini-tiating and maintaining weight loss in a small pilot study byCigaina et al (Obesity Surgery 1999). Currently, it is undergoingevaluation in both Europe and in the U.S. Lead dislodgmentfrom the stomach wall has occurred in 25% of patients in thefirst half of these trials prior to changes in technique. Completedislodgment (CD) can usually be diagnosed by patient symp-toms and/or by radiographs. However, some CD and most par-tial dislodgments (PD) may not be diagnosed non-invasivelyand may impact weight loss if one or both electrodes are dis-lodged. At present, only laparoscopy can be used to determinelead status. This investigation analyzed whether EU may besuccessful as a less invasive diagnostic tool for assessing leadlocation.
Methods: A porcine model was first used to determine 4 maingoals: 1. To assess whether the lead could be visualized. 2. Todetermine whether the electrodes could be identified 3. Tolocate the electrodes both within the stomach wall and outsideit. 4.To determine which layer of the stomach wall the electrodesresided.A lead was placed in an intact en vitro porcine stomach.Three positions were chosen: Both electrodes within the stom-ach wall, one outside the stomach wall, both outside the stom-ach wall. An Olympus radial echoendoscope (UM-20) was usedfor all studies at a 12MHz frequency. EU was performed for eachposition. After this, a study patient with a presumed PD basedon poor weight loss and rising lead impedance was scheduledfor lead replacement. Just prior to laparoscopy, EU was per-formed.
Results: In the en vitro porcine model, EU successfullyimaged stomach wall layers, identified both electrodes withinthe lead and could determine whether or not the electrodeswere in the wall of the stomach. In the patient, EU traced thelead along its course from outside the stomach wall to inside it.It also identified the proximal electrode within the wall of thestomach.This was then confirmed by laparoscopy.
Conclusion: This preliminary report suggests that EU may bea useful, less invasive procedure for assessing lead locationwhen there is a question of dislodgment and the standard radi-ographs are non diagnostic.
90. GASTRIC PACING VERSUS GASTRIC BANDING INMORBID OBESITY – THE MAGDEBURG EXPERIENCE.S. Wolff, C. Gerards*, H. Lippert, P. Malfertheiner*. Dept.Surgery, Dept. Gastroenterology*, University of Magdeburg,Germany
Background: Gastric banding is used in many European cen-ters in surgical treatment morbid obesity. Gastric pacing is anew surgical technology currently under investigation.The aimof this study is to validate the effect of gastric pacing on weightloss in comparison to gastric banding.
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Methods: Patients are randomised to 3 treatment arms forpatients with a BMI > 40, fulfilling WHO criteria for BariatricSurgery: a) n=10, gastric banding (validated method), b) n=10,gastric pacing, switched on, c) n=10, gastric pacing, switchedoff (placebo). Changes in weight, eating behavior and life qual-ity are evaluated before and 6 months after operation.Non-inva-sive follow-up is repeated monthly. Complete re-examination isdone after 6 months.
Results: Twelve patients have been enrolled (10 female, 2male, mean age 32 years, mean BMI 43,1 kg/m2). So far, 8patients were implanted with a gastric pacemaker. Intra-opera-tively, no major complications are to be reported. On the longterm, no deaths or major surgical complications have beenseen. 2 lead dislodgments (prior to improved fixation) and 1chronic gastric wall penetration required re-operation. In thepatients that have completed 6 months follow-up, weight losswas between 5 and 23 kg.
Conclusions: These preliminary data suggest a new way forinducing weight loss in morbid obesity through a surgically safeand feasible laparoscopic procedure. Improvements in the nee-dle of the pacing lead and in fixation of the electrodes will benecessary prior to widespread use.
91. COMPARATIVE STUDY BETWEEN LAP-BAND ANDSWEDISH ADJUSTABLE GASTRIC BANDING.J. M. Fabre, D. Nocca, M. C. Lemoine, C. Vacher, C. de Seguin,E. Renard, J. Domergue. Hôpital Saint Eloi, Montpellier
Background: From September 1996 to March 2001, 476patients were operated under laparoscopy for severe obesity.We compared the results of the 119 Lap-Band (placed between96 and 99) to the 110 SAGB (placed in 99) to have an averagefollow-up of at least 18 months on the latter.
Methods: All the patients were operated on by three seniorsurgeons (JD, CdG, JMF) after a multidisciplinary evaluation(endocrinologist, dietician, psychologist). Mean age of thepatients (39 years), mean preoperative body mass index(44.5Kg/m2), and sex ratio (86% of female) were comparablebetween groups. Conversion rate was 1% (n=5), occurring inthe beginning of our experience, because of gastric injuries (2cases), liver hypertrophy (2 cases) and liver bleeding (1 case).Operative mortality was nil. In spite of the systematic anticoag-ulant treatment, we had a pulmonary embolism with favourableoutcome. Mean hospital stay was 4 days in each group.
Results: 80% and 70% of the patients were followed to 12and 18 months. At one year mean excess weigh loss was 51%and BMI was decreased by 10, whatever the groups.Complications rate was significantly higher with the lap-bandthan with SAGB: pouch dilation 9% (n=11) versus 2% (n=2),slippage 23% (n=27) versus 2% (n=1). These slippages weretreated by repositioning of the lap-band under laparoscopy 12times, by change towards a SAGB under laparoscopy 10 timesor towards a vertical banded gastroplasty 1 time, by removal ofthe band 5 times. Five patients had a second slippage, whichhas occurred 4 times after a first repositioning of the lap-band.Finally, 8 Lap-band were removed (7%) and only one in groupSAGB due to a leakage of the balloon.To date We do not haveany case of gastric erosion with Lap-band or the SAGB
Conclusion: the choice of the material must take account ofthe frequency of the complications for each band. If the majorityof them occur in the first two postoperative years, the real risk inthe long-term is possibly underestimated.We stopped the useof Lap-band because of the high rate of the slippages. Our cur-rent attitude in the event of slippage on Lap-band is to change
it deliberately for the SAGB in a virgin plan of dissection.
92. SWEDISH ADJUSTABLE GASTRIC BAND: PRINCI-PLES OF AN OPTIMAL BAND ADJUSTEMENT.Hans Triaca-Bernasconi, MD; Guido Stirnimann, MD; ChristianKlaiber, MD. Hospital of Aarberg,Switzerland
Background: The postoperative follow-up of patients withSAGB is of great importance in order to obtain good results.Correct fillings and permanent adjustment of the band,adaptedto each patient,are of essential importance.Restriction is a mainfactor for losing weight and determines to a great extent thequality of life of the patients.
Methods: From August 1996 to August 1997 the first group of23 patients was operated at the Aarberg Hospital.The surgeoncarried out the follow-ups.The second group of 40 patients wasoperated between August 1997 and December 1998 and wasfollowed-up postoperatively by an interdisciplinary team. Wecompared the two groups with regard to loss of weight and bandfillings 12 months after the operation.
Results: Both groups were comparable in terms of age,sexand BMI.The interdisciplinary care included a change in the band filling procedure.Both groups receivedtheir first filling of 3-4 ml Jopamiro 4 weeks postoperative(po.).The first group was then given a few fillings with 1-3 mleach filling. Average BMI preoperative (preaop.) 47,02 averageBMI 12 month po. 35,15 average band filling 12 months po 6,67ml.The interdisciplinary group received more frequent fillings, of0,5-1 ml each.Average BMI preop. 47,89 average BMI 12months po.36,96 average band filling 12 months po 4,78 ml.
Conclusion: A continuous interdisciplinary patient care withmore frequent,but smaller band fillings allows to reach analmost equal loss of weight,with less filling amount.This meansmore quality of life, especially with regard to the frequency ofvomiting and a well balanced-diet.
93. A COMPARISON OF COMPLICATION RATES IN 151CASES OF LAP-BANDING AND 174 CASES OF THESWEDISH ADJUSTABLE GASTRIC BAND.James D. Ritchie, MD. Keyhole Surgery Centre, Sydney,Australia
I began to use the Swedish band at the end of 1998.My rea-sons for changing devices was the high rate of revisionalsurgery I experienced with the Lap Band.29% of my LapBanding patients required revision with repositioning orremoval.I believe the cause for this was the placement of theband across the posterior wall of the stomach high in the lessersac below the pars flaccida.The tendency to slip was alsoaggravated by the smooth hard nature of the device.This allowsfor early displacement and in time this develops into a full scaleslippage with obstruction.The band itself does not adhere to thestomach but encapsulates leaving an opening through whichthe the stomach can prolapse especially when the band isdeflated.
I found the constant presentation of obstructed dehydratedpatients requiring urgent I.V.therapy and surgical correction tobe such a burden that I resolved to change devices.Most reportsabout the Swedish band indicated that it had a very low slippagerate so I resolved to change to this device.The low incidence ofslippage is due to placement of the band through the pars flac-cida thus providing secure posterior fixation.A further factor maybe the low pressure balloon which deforms around the stomachand which may grip it gently making it less prone to early slip-page.
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My experience to date with the SAGB indicates weight lossescomparable to the Lap Band.Complications are one greater cur-vature slip,one erosion,two avulsions of tubing from the injectionport,one perforated tube and two displacements of the port intothe abdominal cavity giving a total complication rate over twoyears of 4%.The device itself is soft and more easily damagedthan the Lap Band.Great care must be taken to avoid roughhandling and needle puncture.I have damaged 4 bands.Thedamage was recognised at the time and the bands replaced.Allbands should be tested for leaks before placement and at theend of the procedure so as to minimize the chance of a leakingband being left in situ.
94. REDUCTION OF OBESITY-RELATED CO-MORBIDITYAFTER LAPAROSCOPIC GASTRIC BANDING (SAGB®).A. Glättli1,3 G. Stirnemann2, S. Schlatter1, R. Stouthandel1, H.Triaca2, Ch. Klaiber2. Zieglerspital Bern1, Spital Aarberg2,Salem-Spital Bern3, Switzerland
Background: Laparoscopic implantation of an adjustable gas-tric band has in Europe become a standard treatment of morbidobesity. The aim of the operation is not only weight loss but alsoreduction of obesity-related co-morbidity.We studied the resultsin our patients with respect to the metabolic syndrome(Diabetes mellitus, Dyslipidemia, Hyperuricemia,Hypertension).
Methods: From 8.1996 to 9.2000 we operated on 310patients (M:W = 61:249; median age: 38.3 (18-64) years) byimplantation of a Swedish Adjustable Gastric Band (SAGB®).BMI: 44.6 (34-65) kg/m2, overweight: 54 (22-116) kg. The meta-bolic syndrome was defined by measuring the following para-meters: Diabetes mellitus (HbA1c), Dyslipidemie(Cholesterol/HDL-C), Hyperuricemie (uric acid), Hypertension(systolic and diastolic blood pressure). Only patients were eval-uated with a follow up of 3 months and more.
Results: Median operating time was 90 (30-235) min., con-version rate was 0.97%. Morbidity within 30 days was 1.61%,late morbidity occurred in 13.2% of all patients. No mortality.After a mean follow up time of 24 (3-48) months 47.3% ofpatients lost 50 % or more of their overweight. Reduction of co-morbidity is shown in the figure below (numbers are % patho-logical values). Months 0 6 12 18 24 36 Patients 310 247 20693 133 35 HbA1C 23.7 16.6 13.7 6.1 10.6 6.9 Chol/HDL-C 31.019.3 12.2 4.6 5.2 2.1 Uric acid 50.6 40.3 28.6 32.3 23.5 17.2Systolic 30.0 32.6 31.7 33.3 24.0 25.0 Diastolic 25.1 21.3 11.527.8 12.0 20.8 Diabetes mellitus, Dyslipidemie undHyperurikemie was eliminated or improved in a significant waywithin time and Hypertension showed a tendency towardsimprovement.
Conclusion: Laparoscopic gastric banding has a positive andsignificant effect on the metabolic syndrome and gives besidesweight loss an amelioration of patients health.
95. BILIOPANCREATIC DIVERSION WITH ROUX-EN-YGASTRIC BYPASS (BPD WITH RYGBP) FOR THE SUPEROBESE: PRELIMINARY RESULTS.Mead Nancy, Skroubis George, Kritikos Neoklis, Soulikia Klea,Loukidi Aggeliki, Kalfarentzos Fotis. Nutrition Support andMorbid Obesity Clinic, Surgical Department, University Hospitalof Patras, Greece
Background: Super obese patients who undergo purelyrestrictive bariatric procedures or standard gastric bypass oper-ations often fail to maintain satisfactory long-term results.
Methods: From June 1994 to April 2001, 196 morbidly obesepatients underwent various bariatric procedures at our institu-
tion. Of these patients, 70 with a BMI > 50 (average age 37.4years, average weight 150.8 kg, average BMI 55.8) underwentbiliopancreatic diversion with Roux-en-Y gastric bypass (gastricpouch 15±5ml, alimentary limb 350cm with common limb100cm). Cholecystectomy and appendectomy were also per-formed at the time of surgery provided these procedures hadnot been performed at an earlier date. All patients were seen at1, 3, 6, 9, 12, 18 and 24 months postoperatively and yearlythereafter. Average follow-up time to date is 18.8 months or 1.6years (2-55 mos.) and follow-up is 100%. A multivitamin andmineral supplement and 2 gr. calcium are prescribed for allpatients daily as well as 80 mg iron in premenopausal women.Radiology examination is performed in all patients on the 4thpostoperative day and at each yearly visit in order to check forstaple-line disruption.
Results: Early postoperative morbidity (£ 30 days) was12.85%. Late postoperative morbidity (>30 days) was 17.1%.There was no early or late mortality. Weight loss resultsexpressed as average % excess weight loss (EWL) are as fol-lows: 56.2% (29-84%) at 1 year (38 patients), 58.5% (34-78%)at 2 years (21 patients) and 52.2% (28-91%) 3 years followingsurgery (11 patients). Further separation of weight loss resultsby sex showed that EWL was significantly higher in males at alltime periods. Nutritional complications included one case ofhypoalbuminemia (1.4%) in a female patient 20 months follow-ing surgery, which was easily corrected by administration ofTPN and subsequent increase in dietary protein intake. Othernutritional complications included anemia (27.7% at 1 year,37.5% at 2 years and 33.3% at 3 years), iron deficiency (18.7%at 1 year, 25% at 2 years and 55.5% at 3 years) and vitamin B12deficiency (27.7%, 31.2% and 44.4%, respectively), both ofwhich were treated with extra supplementation. There was noclinical symptomatology, and no hospitalization for these defi-ciencies was necessary. Evaluation by BAROS for all patientswith at least 6 months follow-up was unsatisfactory in onepatient (1.63%), fair in 4 patients (6.5%), good in 20 patients(32.7%), very good in 25 patients (40.9%) and excellent in 11patients (18%). Finally, we found significant improvement or res-olution of all preexisting comorbidities. Most notably, sleepapnea, hypoventilation syndrome and dyslipidemias were com-pletely resolved within the first month following surgery.
Conclusion: BPD with RYGBP appears to be a safe andeffective bariatric procedure for the super-obese patient.
96. LONG-TERM RESULTS OF BILIOPANCREATIC DIVER-SION IN SUBJECTS WITH PRADER-WILLI SYNDROME.Francesco Papadia, Giuseppe M. Marinari, Giovanni Camerini,Federica Murelli, Paola Marini, Cesare Stabilini, Flavia Carlini,Nicola Scopinaro. DICMI, Semeiotica Chirurgica R, Universityof Genoa School of Medicine, Genoa, Italy
Background: The Prader-Willi Syndrome (PWS) is a congen-ital disorder characterized by neonatal hypotonia, short stature,hypogonadism, mental retardation and compulsive hyperpha-gia, with the development of early obesity. Since gastric restric-tive surgery requires strong patient’s compliance to achieveweight loss results, this approach has failed in fighting PWSpatients’ obesity, whilst the malabsorptive approach seems themost appropriate one.
Methods. 15 (9 M) patients with PWS were submitted to BPDbetween June 1986 and February 1996. In all cases PWS diag-nosis, made at a mean age of 6.5 yr. (6 mo-14yr), was done inchildren’s hospital. According to Holm’s criteria, at the time ofthe operation all of the subjects had a total score of 8 or more.
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Preoperative mean age was 21 (12-31) yr., mean weight 127(84-164) kg, mean excess weight 74 (34-116) kg, correspond-ing to mean 142 (67-237) % of the ideal, mean BMI 53 (36-72),mean waist/hip 0.97 (no differences between M and F). At thetime of operation 4 subjects had hypercholesterolemia, 3 hadtype II diabetes mellitus and 4 had hypertension. Indication toBPD was BMI >40 and, in 3 cases, >35 with concurrent meta-bolic complications.Mean follow-up is 8.5 (4-13) yr.W.A.I.S.Testfor I.Q. assessment was performed at a recent visit in each sub-ject, with a mean score of 72 (56-84). An arbitrary score basedon lifestyle was given to each subject: 1 (at home with parents,total inaction and near absence of interest in life); 2 (at homeparticipating in housework, irregular attendance at specific ref-erence center); 3 (regular job and /or regular attendance at spe-cific center).
Results: No perioperative complications were observed.Mean body weight showed a percent loss of the initial excess(IEW%L) of 59±15 at 2 yr. and of 56±16 at 3 yr., and then a pro-gressive regain: at 5 yr. the IEW%L was 46±22 and at 10 yr.40±27, with marked interindividual differences among the oper-ated patients. Actually, according to BAROS criteria for weightloss, of the 14 subjects at 5 yr., 8 (57%) had excellent or goodresult (IEW%L ³ 50), 3 (21%) fair result (IEW%L between 25and 49), and 3 (21%) were failures (%EWL £ 24); of the 7 sub-jects with a 10-year follow up, 3 had good result, 1 fair result and3 were failures (1 died during his 9th postoperative year).Spearman rank test did not demonstrate any correlationbetween weight loss at 5 yr. and preoperative age, initial percent excess weight, preoperative BMI, preoperative waist/hipratio, waist circumference alone, age at diagnosis, and IQ score,while a correlation was found (Spearman r= 0.8548, p <.0001)between weight loss at 5 yr. and lifestyle score. Both type II dia-betes mellitus and hypercholesterolemia disappeared already 1month after surgery with no relapse during the whole follow-upperiod, even in patients who failed weight control. Hypertensionwas cured in all the 4 affected patients within the 1st postoper-ative year. 1 patient had recurrent protein malnutrition and 24months after BPD underwent surgical revision with elongation ofthe common limb, 2 subjects had an incisional hernia, 1 devel-oped severe bone demineralization; 1 of the unsuccessful sub-jects died on the ninth postoperative year from respiratory fail-ure, while another subject with very good weight loss result diedon the 6th year from causes unrelated to either obesity or BPD.
Conclusion:Though in PWS patients a full recovery from obe-sity cannot be achieved with any known treatment, BPD has tobe considered for its value in prolonging and qualitativelyimproving the patient’s life, since it provides the best knownweight loss results.
97. BILIOPANCREATIC DIVERSION, POSTOPERATIVEMANAGEMENT CHALLENGES, EXPERIENCE WITH 198CASES OVER 7 YEARS.James D Ritchie, MD. Keyhole Surgery Centre,187 MacquarieSt, Sydney, Australia
Background: My experience with biliopancreatic diversionbegan 7 years ago.I was looking for a procedure to offer patientswho had failed with restrictive procedures such as banding orstapling.Many of my early patients had had a number of suchprocedures.Following a visit to Prof Scopinaro’s unit in 1993 Icommenced my experience with biliopancreatic diversion.
Methods: The early results proved so successful that I havecontinued to offer this procedure to patients who have failedrestrictive procedures or who are superobese.Many patients are
requesting the procedure as their preferred option for bariatricsurgery as they perceive it to be more reliable and to be lessrestrictive than banding.I feel it is particularly suitable for malesthe superobese the diabetics those who have hyperlipidemiathose who are sweet eaters those who suffer from refluxoesophagitis.
Results: Follow up,however, indicates significant incidencesof deficiencies of fat soluble vitamins The following incidencesof deficiencies have been documented Vit A 10%, Vit D 12%, VitK 6% Iron 14.6%, Calcium 1.5%, Protein 2%. The exact inci-dence of the deficiencies is under review at present andupdated data should be available for presentation atIFSO.There is a sizeable incidence of stomal ulceration (3%)and of incisional herniae (3.5%).Results and other complica-tions are presented.
Conclusion: Biliopancreatic diversion is one of the most effec-tive procedures available to control morbid obesity.Patients whoundergo this surgery,however must commit to remaining undersurveillance as they are at risk from the side effects of malab-sorption.They must take vitamin and mineral supplements inlarge amounts to offset the loss of vitsA,D,E & K, calcium andiron.At present my preferred supplement is Vita4Life.They musteat 100gms of good quality protein and avoid fats in theirdiet.They must have 6 monthly biochemistry to detect and treatany developing deficiencies.Aggressive techniques such asTPN or iron infusion are at times required to maintain normalbiochemistry.
98. OUR BARIATRIC SURGERY EXPERIENCE WITH BILIO-INTESTINAL BYPASS.Bressani Doldi Santo, Micheletto G., Perrini M. Cattedra diChirurgia Generale dell’Università degli Studi di Milano - IstitutoClinico Sant’Ambrogio (Direttore: Prof. S.B.Doldi); Centro per laFarcomacoterapia delle Malattie Nutrizionali e Metaboliche “E.Genovese e R. Klinger” (Direttore Scientifico: Prof. S.B.Doldi)
Background: Since 1974 we have performed these bariatricoperations : 312 jejuno-ileal bypass (JIBP); 80 bilio-intestinalbypass (BIBP); 102 horizontal gastroplasty; 44 silastic ring ver-tical gastroplasty; 325 adjustable gastric banding (262 Lap-band®) and 240 intragastric balloons (BIB®). After 1979 whenD.Hallberg popularized bilio-intestinal bypass, approximately fora decade we used this procedure only in morbidly obesepatients with previous hepatic diseases. Since 1990, we haveadopted definitively bilio-intestinal bypass for all cases thatcould be appropriately treated with malabsoptive procedure.
Methods: 80 patients (Male: 36; Female: 44); mean age 35.2± 8.3 years; preoperative mean weight Kg 152.3 ± 22.8; BMI53.8 ± 5; mean follow-up 8 years.The decision to resort to BIBPwas adopted by a multidisciplinary team. On discharge patientswere subjected to a multivitamin and multielectrolyte therapy, toantidiarrhoea drugs when necessary and monthly check-up dur-ing the period of weight loss (18-24 months). The indicationsand contraindications we have followed were the same adoptedat NIH conference (1991).
Results: Two years post-operatively 38,7% of initial weighthad been lost by 91.2% of the patients, with the reduction of theexcess weight of 78.2% and in BMI of 37.7%.The weight reduc-tion was stable. Insufficient weight loss (<20% initial weight) was5%. The most important early and late complications were:severe diarrhoea with electrolytes unbalance (1.2%), abdominalbloating (6.2%) and incisional hernias (11.2%).The reversal andconversion rate was 5% and death rate 0%. No one of ourpatients had liver failure or interstitial oxalic nephritis.
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Conclusion: In comparison with JIBP, the bilio-intestinalbypass produces a satisfactory weight loss in more patients(91% vs. 83%) with less early and late complications and nomortality . Moreover, the less severe diarrhoea provides animportant clinical advantage and improvement in the quality oflife. By our experience we can state that the BIBP still has animportant role in bariatric surgery, above all in morbidly obeseyoung patients with BMI > 50, for patients refusing drastic long-term food intake restriction, for patients with compulsive bulimiaand following unsuccessfull gastric restrictive surgery. At last wewant to emphasize that BIBP is completely reversible and lessaggressive than the other malabsorption procedures. Quiterecently we performed bilio-intestinal bypass by laparoscopictechnique: that is of great benefit for the patients (less pain,shorter stay in hospital, less cardiorespiratory and thromboem-bolic complications, better aesthetic result) and for the commu-nity (less costs).
99. INTESTINAL OBSTRUCTION AFTER MALABSORP-TIVE PROCEDURES: STILL A POTENTIALLY DEADLY COM-PLICATION.Kenneth B. Jones, Jr, MD. CHRISTUS Schumpert HealthSystem
Background: With the recent surge in interest in bariatricsurgery, particularly with laparoscopic Roux-en-Y gastricbypass, although infrequent, intestinal obstruction is and will beseen more often as our patient population mushrooms. At theexpense of traditional bariatric surgery principles in favor ofexpediency, we frequently cut corners to achieve our goalslaparoscopically, lulling ourselves into a sense of complacency,while increasing the risk of small bowel obstruction at or distalto the entero-enterostomy.
Methods: Over a 15 year period from 1986 to May of 2001, in1,996 primary and conversion RYGBP’s, there were 15instances of subacute and acute small bowel obstruction, prin-cipally at the entero-enterostomy. This can lead to acute gastricdilatation, as the biliopancreatic limb is obstructed with subse-quent ischemia and pressure necrosis, a potentially deadlyproblem. Physical signs and symptoms include sustained tachy-cardia, oliguria, hypotension and biliary regurgitation and vomit-ing. Frequently a palpable epigastric mass is noted. Laboratorydata is inconsistent, but bilirubin and amylase may be elevateddue to the back pressure thus produced. Emergency radiologicexamination is imperative. However, the standard acute abdom-inal series frequently looks unremarkable, and upper GI seriesmay not help if the alimentary and common limb are notobstructed. Abdominal ultrasound is usually helpful, but CT ofthe abdomen is always diagnostic of the massively dilated, usu-ally gasless bypassed distal stomach and proximal small bowel.
Results: In the cases presented, diagnoses included internalhernia, adhesions, retrograde intussusception at the entero-enterostomy, cecal volvulus, and a spontaneous hematoma ofthe small bowel wall.
Conclusion: Many bariatric surgeons are alone in their com-munities. Therefore, they need to make their non-bariatricsurgery colleagues, medical, surgical, and primary care awareof these potentially deadly problems and the diagnostic tools toaid in their solution.
100. MALABSORPTIVE SURGERY IN THE THERAPY OFSUPEROBESITY: REASONS TO CHOOSE BETWEEN THE“DOC” B.P.D TECHNIQUE AND ITS VARIANTS, GASTRICBYPASS AND INTESTINAL BYPASS.
C. Vassallo, M. Andreoli, G. Berbiglia, A. Pessina, D. SavioniPrivate Practice, “Morelli” Clinic, Pavia, Italy
Background: We started to perform bariatric surgery in 1978.Since then until today we have used 4 different malabsorptivetechniques in all on 235 superobese patients, on a total of 1242patients operated. Aim of this review is to try and standardizethe reasons to choose between the various malabsorptive tech-niques, independently from their evolution in time, as thesetechniques are still used.
Methods: This review concerns 21 intestinal bypasses, 128“Doc” B.P.D.s, 82 T.G.R./D.S./B.P.D.s* and some gastricbypasses in the last three months. All these techniques havebeen our first choice, except 11 T.G.R./D.S./B.P.D.s, which wereperformed to correct gastric restrictive surgery.
Results: The basal BMIs of the 4 groups of patients were sim-ilar.The average excess body weight in the cases with a 5 yearsfollow-up was equal to 29%. The effectiveness on dysmetabolicsyndromes and the percentage of complications are differentand it is just on this basis that we can elaborate some choosingprinciples.
Conclusions: The “Doc” B.P.D. technique is particularly effec-tive for the treatment of dysmetabolic syndromes; its gastricpreservation variant is quite fit to treat gastric restrictive surgeryfailures. The intestinal bypass is more easily and quickly per-formed, but has some drawbacks in the short and mediumperiod.
101. FLEXIBLE ENDOSCOPY IN THE MANAGEMENT OFPATIENTS UNDERGOING ROUX-EN-Y GASTRIC BYPASS.Bruce Schirmer, M.D., Anna Miller, R.N. University of VirginiaHealth Sciences Center, Charlottesville, VA, U.S.A.
Background: Flexible upper endoscopy (FUE) is an importantdiagnostic and therapeutic tool in the management of uppergastrointestinal diseases. We examined the role of FUE in themanagement of patients undergoing Roux-en-Y gastric bypass(RYGP).
Methods: All patients undergoing RYGB by a single surgeonat a single institution from 1986 to 2001 were studied.Preoperative FUE was performed by the surgeon on an outpa-tient basis to assess the anatomy of the esophagus, stomach,and duodenum.Since 1997, gastric biopsies were obtained dur-ing FUE for either histology or CLO testing for the presence ofH. pylori. Colonized patients were treated preoperatively withtriple therapy. Postoperatively, FUE was performed by the sur-geon as indicated clinically for management of symptoms sug-gesting anastomotic stenosis, upper gastrointestinal bleeding,inflammation, or ulcers. Endoscopic balloon dilatation was per-formed as indicated using a size 18-20 Fr. balloon. Patient andprocedure data were recorded in a database. Statistical analy-sis was performed using Chi square analysis.
Results: A total of 560 patients underwent RYGB during thestudy period. Of these, 536 underwent preoperative FUE.Endoscopic findings changed or altered the operative proce-dure in 26 patients (4.9%). Preoperative testing for H. pylori wasperformed for 206 patients, of whom 62 (30.1%) were positive.Patients tested for H. pylori had a lower incidence of postopera-tive marginal ulcers (n=5, 2.4%) than did patients who did notundergo such screening (n=24 of 354, 6.8%, p<0.04).Postoperatively, 60 patients underwent 87 endoscopic balloondilatations for stenosis of the gastrojejunostomy. In addition,46patients underwent 58 FUEs that proved negative for suchstenosis. A total of 69 patients underwent 93 additional diag-nostic or therapeutic FUEs by the surgeon in the postoperative
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period, including investigation of symptoms of pain, bleeding,persistent vomiting, or weight regain.
Conclusion: Flexible upper endoscopy (FUE) is a tool whichmay be used by the surgeon in the preoperative and postoper-ative management of patients undergoing RYGB to modify ther-apy, improve outcomes, and diagnose and treat postoperativecomplications.
102. OBJECTIVE ASSESSMENT OF THE EFFECT OFLAPAROSCOPIC GASTRIC BYPASS ON ESOPHAGEAL pHAND MOTILITY IN MORBIDLY OBESE PATIENTS WITHGERD.Emma J. Patterson MD, Yashodhan S. Khajanchee MBBS MS,Lee L. Swanstrom MD. Legacy Health System, Portland,Oregon, USA
Background: Gastroesophageal reflux disease (GERD) isprevalent among morbidly obese patients. Although bariatricsurgery often improves reflux symptoms, the objective effects ofbariatric surgery on esophageal physiology and pathologicGERD are less well documented.The aim of this study was toanalyze the effect of gastric bypass surgery on esophagealmotility and acid reflux, since it is possible that asymptomaticacid reflux may occur even with a small (15 ml) gastric pouch,or that a small pouch may exacerbate esophageal motility dis-orders.
Methods: In our minimally invasive bariatric surgery program,morbidly obese patients with reflux symptoms routinely undergoesophageal manometry and 24-hour ambulatory pH studiesprior to laparoscopic Roux-en-Y gastric bypass surgery. Theseobjective tests of esophageal physiology are repeated one yearpostoperatively.
Results: Six female patients with a mean age of 40 years(range 19-61) have completed the protocol, at a mean of 13.8months post-operatively (range 11-15). Five of six patients hadnormal preoperative motility, and all of these patients experi-enced complete resolution of reflux symptoms and a drop ofDeMeester score to normal levels.The other patient had a spas-tic esophagus preoperatively, which improved somewhat aftersurgery. Her reflux symptoms improved but did not completelyresolve, and her DeMeester score increased from 9 to 18 aftersurgery. Data means are presented in the table below, withresults of paired t-tests.
BMI Reflux DeMeester No. of Mean %Relaxation
(kg/m2)Symptom Score Episodes LES of LESScore Acid (mm hg)
p-Value 0.002 0.003 0.14 0.05 0.45 0.03Conclusion: The results of this pilot study suggest that gastric
bypass surgery for morbid obesity improves GERD both symp-tomatically and objectively.There appears to be no deteriorationin esophageal motility in the short-term, and preoperative motil-ity disorders may be predictive of persistent postoperativeGERD.
103. PROPHYLACTIC CHOLECYSTECTOMY WITH GAS-TRIC BYPASS OPERATION – INCIDENCE OF GALLBLAD-DER DISEASE.Daniel Igwe Jr. MD, Malgorzata .Stanczyk MD, Basil Felahy, MDFRCS, Hoil Lee MD, E.James MD, Nicole Fobi MD, MAL Fobi,
MD FACS. Center for Surgical Treatment of Obesity, Tri-CityRegional Medical Center, Hawaiian Gardens, USA
Background: Morbid Obesity is one of the major risk factorsfor gallbladder disease, and this risk is even greater followingrapid weight loss. Because of this, prophylactic cholecystectomyis offered to patients undergoing the Transected Silastic RingVertical Gastric Bypass ( Fobi Pouch Operation) at the Centerfor Surgical Treatment of Obesity. A study was undertaken todetermine the incidence of pathologic gallbladders in patientsundergoing prophylactic cholecystectomy
Method: The records of all patients who underwent the FobiPouch surgery from June 1999 to Nov.2000 were reviewed.Pathologic findings of the gallbladder were documented ascholelithiasis, cholecystitis, cholesterolosis, polyps, carcinomasor normal.
Results: 761 patients had the Fobi Pouch. 178 (23%) patientshad cholecystectomy prior to the surgery. 154 (20%) had gall-stones documented by ultrasound and had cholecystectomy atthe time of the surgery. 286 of the 429 patients with negativepreoperative findings by ultrasound had pathologic evidence ofgallbladder disease.
Conclusion: The incidence of gallbladder disease with nega-tive preoperative findings is high enough in morbidly obesepatients (67%) to warrant routine cholecystectomy at the time ofweight loss operation.
104. INITIAL EXPERIENCE WITH OPEN AND LAPARO-SCOPIC GASTRIC BYPASS IN NAPLESLuigi Angrisani, Vincenzo Borrelli, Michele Maresca, MicheleLorenzo, Gaetano Cimmino, Monica Ciannella, Monica Giuffrè,Annalicia Mozzillo. Unit of Endoscopic Surgery, “S.GiovanniBosco” Hospital, Naples, Italy
Background: The use of Open (RYGBP) and LaparoscopicRoux-en-Y Gastric Bypass (LRYGBP) for the treatment of mor-bid obesity has been limited in Italy. This is a report of the earlyresults obtained with Gastric Bypass performed via laparotomyand laparoscopy in a single centre with previous and currentexperience in Lap Band System® procedures (LASGB®).
Methods: From January 2000 to April 2001, 62 patientsreferred for surgery were selected according to the following cri-teria: LASGB® in highly motivated patients with BMI < 50,LRYGBP in those without compliance for LASGB and BMI £ 50,RYGBP in pts with BMI >50.
Results: Twentyseven pts (27/62=43.5%) were selected forLap Band (23F/4M; mean age 32.8, range: 21-52 yrs; mean BMI43.8, range 35-51); the other 35 pts (56.5%) underwent GastricBypass, 17/35 (48.6%) performed via laparoscopy (16F/1M;mean age 34.2, range 19-50 yrs; mean BMI 44.6, range 39-50),the remaining via laparotomy (11F/7M mean age 38.4, 20–56yrs; mean BMI 52.7, range 30-64) . No mortality was observed.One patient (5.9%) was converted to open tecnique for a pos-terior wall leakage of gastroenteric anastomosis detected bymethylene blue test. Concomitant cholecystectomy was per-formed in 7 patients.Mean post operative hospital stay for openand laparoscopic bypass was 8±5 and 5±3 days, respectively.Postoperative wound infection was observed in 10/18 (55.5%)patients undergoing RYGBP and in 1/17 (5.9%) patients oper-ated by laparoscopy.Mean post-operative BMI at 6th month fol-low up, already performed on 9 pts with RYGBP and on 6 ptswith LRYGBP, was 31.8±7.2 and 29.1±9.8 respectively.
Conclusion: Differently from LASGB®, training in openRYGBP is required to safely approach the same operation bylaparoscopic techniques. Selection of patients with BMI £ 50 is
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advisable in the beginning period of LRYGB.
105. LEAKAGE AFTER ROUX-EN-Y GASTRIC BYPASS.A. Westling MD, PhD, Sundbom MD & Gustavsson S AssocProf. University Hospital, Uppsala, Sweden
Background: Leakage is a feared complication to Roux-en-yGastric bypass (RYGBP). Our report deals with leaks that haveoccurred during the recent 5-year period.
Methods: A total of 285 patients underwent RYGBP during1996-2000. In 94 patients (median BMI 38 kg/m2) RYGBP wasa revisional procedure after previous failures with VBG andbanding procedures. 191 patients (BMI 44 kg/m2) had notundergone obesity surgery before. 44 procedures were donelaparoscopically and 30 with Hand-assisted laparoscopic tech-nique. In revisional procedures the gastro-jejunostomy waseither hand-sewn or constructed with linear stapler + manualclosure of defects. In the first 116 primary cases the anastomo-sis were made by linear stapler but in the most recent 75patients a circular stapling technique was used.We did not over-sew any staple lines, neither did we do any attempts to checkfor leaks intraoperatively. Postoperatively all patients weresupervised carefully at the surgical ward. Per oral contrast stud-ies were performed on wide indications but not routinely.
Results: We had a total of 5 patients with clinically significantleakage requiring emergency re-operation. Four leaks occurredafter revisional procedures (4 %) while only one leak (0,5 %)was observed after RYGBP performed as the first bariatric pro-cedure. Relaparotomy was undertaken at postop day 1 (n=1),day 2 (n=3) and day 4 (n=1). One leak occurred after linear sta-pling and at laparotomy we were able to identify the leaking spotin that part of the anastomosis that had been hand-sewn. In theremaining four patients we could not identify the exact locationof the leak. In one case we suspected that the gastric staplinghad failed because this patient developed a gastro-gastric fis-tula. No leakage has been observed after circular stapling tech-niques. All patients were treated with large-bore drainage tubesand antibiotics.The median (range) number of days with venti-latory support, in ICU and in the surgical was 1 (0-5), 4 (2-9)and 21 (19-36), respectively.No mortality.
Conclusion: Leakage in the gastro-jejunostomy is a seriouscomplication after RYGBP requiring re-laparotomy, ICU treat-ment and prolonged hospital stay and convalescence.Leakageoccurs more frequently after RYGBP as a revisional procedure.
106. A NEW TECHNIQUE FOR MAKING A FULLY STAPLEDDIVIDED GASTRIC BYPASS: 1-3 YEAR RESULTS.J. Hedenbro, S. F. Frederiksen, M. Flemming. Department ofSurgery at Lund University hospital, Lund, Sweden
Background: Gastric bypass with Roux-en-Y reconstruction isthe bariatric procedure of choice.The evidence support a smallpouch separated from the main stomach.The major hazard withthis operation is the difficult upper anastomosis, where a leakjeopardises patient life. The terminal anastomosis is a logicalchoice, for ease of approach as well as because of gastric vas-cular anatomy. Another risk factor to consider is that of stapleline dehiscence, jeopardising long-term weight development. Itthus seems desirable to have a full separation of the gastricpouch. We have devised a way of making a fully stapled gastricbypass with complete separation of the pouch. Operative dataand intermediate term (1-3 years) follow-up data are presented.
Method: The stomach is first partially transected perpendicu-lar to the lesser curvature 4.5-5 cm below the cardia with a lin-ear cutting stapler. The anvil of the CEEA 28 mm is then
inserted through a small gastrotomy in the main stomach, itspoint brought out through the upper staple line close to thelesser curve. The gastrotomy is closed and the pouch is com-pleted with a second application of the linear cutting stapler,from the bottom of the first one up to the angle of His. This rowmight need oversewing for haemostatic reasons. The Roux-Y-loop is then brought up behind the stomach and colon. TheCEEA is introduced through a jejunotomy, an end-to-end anas-tomosis performed and its integrity checked. The jejunotomy isclosed, and an enteroanastomis performed, according to patientBMI between 80 and 225 cm below the pouch-jejunal anasto-mosis. All patients were started on oral intake day 1 postop. anddischarged at a daily intake of 2000 mls with prescriptions forsupplementary iron and vitamins incl. B12. They were followed-up in the outpatient department at 1, 3, 6 and 12 months, andthereafter annually.
Results: Since October 1997 we have performed 181 suchanastomoses in consecutive patients with no leaks, no gastro-gastric fistulae and no mortality. 100 were primary operationsand 81 revisional procedures following failed VBGs or(adjustable) gastric banding. Mean operative time in primaryoperations was 91 minutes and operative blood loss was 121mls, 350 in revisional. Postoperative hospital time was 4.6 (3-9)days (median, range) with no difference between primary andrevisional operations. BMI at operation, 1 and 3 years were forprimary procedures 47.5, 29.5 and 28.7. For revisional proce-dures corresponding values were 39.3, 30.8 and 32.1. Therehave been three symptomatic jejunal ulcers. Four patients hadclinically significant reflux preoperatively; it has resolved in allfour. No patient has developed reflux problems. Two patientshave had their pouch-jejunal anastomoses dilated, 8 and 12months postoperatively. One of these patients had a longstand-ing history of ulcer. Stricture formation recurred quickly afterdilatation and she had her anastomosis refashioned withoutcomplications. No patient has needed hospitalisation for mal-nourishment.
Conclusion: A new technique for gastric bypass was intro-duced. It gave short operating times and short hospital stay. Themorbidity was low, with no leaks and no mortality. Three-yearweight data show good results, on par with what is found in theliterature.
107. LAPAROSCOPIC GASTRIC BYPASS: RESULTS IN 76PATIENTS.Hans Lönroth, Torsten Olbers, Lars Lundell. Department ofUpper GI-Surgery, Sahlgrenska University Hospital,Gothenburg, Sweden.
Background: Gastric by-pass (GBP) is by many consideredas the “gold standard” in bariatric surgery. The technique com-bines excellent weight reduction with few eating disturbances.This operation has since 1995 been carried out with laparo-scopic technique. Result from our initial series of 76 patients ishereby presented.
Methods: During the period October 1995 to March 2000 76consecutive patients were operated on with a laparoscopicGBP. In the first 6 patients an anticolic omega-loop was con-structed, thereafter 25 patients were operated on with a retro-colic, retrogastric Roux-en-Y construction.In the last 45 patientsthe Roux-limb has been placed anticolic and antigastric.Perioperative data were collected and the patients were fol-lowed prospectively postoperatively with respect to weightdevelopment, re-operations and eating disturbances.
Results: Three patients were converted to open surgery
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because of a large steatotic left liver lobe. There were threepostoperative leakages; two at the gastroenteroanastomosisand one at the enteroanastomosis.All of them were early iden-tified and re-operated. Six patients had postoperative bleedingwhere two was re-operated though without finding of a definitebleeding source. One patient succumbed after developingdilatation of the remnant stomach with following peritonitis andmulti organ failure.Three patients have been re-operated due toileus (10 days, 5 weeks and 5 years postoperatively).All of themwere operated with the retrocolic Roux-en-Y construction. Onepatient has been operated for a perforated ulcer. Six patientsreported vomiting, most often due to overeating. Four patientsreported dumping symptoms. The weight development corre-sponds to a 70% reduction of excess body weight at 1-2 yearspostoperatively. This weight reduction has been rather consis-tent in the follow-up period.
Conclusion: This series contains all the patients who wereoperated during the development of a totally new technique toperform GBP laparoscopically. You must bear this in mind whenyou notice a somewhat high frequency of complications includ-ing one death. Per today we consider laparoscopically per-formed GBP to be a safe operation where the results concern-ing weight development and eating quality is comparable tothose seen after GBP done through a laparotomy.
VIDEOS:
108. MICROPOUCH GASTRIC BYPASS.James A. Sapala, MD, Michael H. Wood, MD, Michael P.Schuhknecht, DO, Thomas M. Flake, Jr., MD, M. AndrewSapala, MD. St. John Detroit Riverview Hospital, Detroit, MI,USA
This video describes the major technical features of theMicropouch Gastric Bypass. These include mobilization of thegastric fundus, transection of the left phrenoesophageal liga-ment and a single layer closure of the retro-colic Roux en-Y gas-trojejunostomy. It also illustrates the use of hemaseel fibrin glueto “seal” the anastomosis.
The micropouch operation has been performed by our groupfor seven years. In more than 1660 patients the micropouch hasnot required revision for pouch enlargement, marginal ulcerationor staple line dehiscence.Percent excess weight loss was 68.8at one year and 76.6 at two years following operation. Theseresults equal or surpass those reported after other gastricbypass operations utilizing the 30cc pouch.
109. LAPAROSCOPIC GASTRIC BYPASS EXACTLY REPRO-DUCES THE OPEN TECHNIQUE.Díez del Val I, Martínez Blázquez C, Vitores López JM, SierraEsteban V, Valencia Cortejoso J, Sardón Ramos JD. HospitalTxagorritxu, Vitoria-Gasteiz, Spain.
Laparoscopic surgery has drastically improved the outcomeof patients after gastric bypass: abdominal discomfort, respira-tory and abdominal wall complications have almost disappearedand hospital stay has been shortened.After a 3-year experiencewith Roux-en-Y isolated gastric bypass and more than 150patients operated on by this technique, we currently perform thelaparoscopic procedure reproducing step by step the openapproach.
First of all, a small isolated gastric pouch is constructed,starting at the lesser curvature 5 cm distal to the gastroe-sophageal union to reach the angle of His. To avoid esophagealinjury, the anvil is introduced transabdominally through a small
hole in the left lower corner of the gastric pouch and pulleddown to be retrieved near the transverse suture line.
The patient is placed in the Trendelemburg position to retrievethe Treitz ligament and measure a biliopancreatic limb of 40 to200 cm depending on the BMI. A side-to-side anastomosis ismade by using a linear stapler and the enterostomy is closedmanual or mechanically. The alimentary limb is passed to theupper abdomen following a retrocolic, retrogastric way, using aPenrose drain as a traction device.
The circular stapler is introduced directly through the accessopened by a 18mm port into the blind end of the Roux limb tocreate an end-to-side gastrojejunostomy, which is calibrated tothe internal diameter of the stapler (12 mm).
110. BIG GUYS - LAP BANDING FOR SUPER OBESITY.George A Fielding. Wesley Hospital and Royal; BrisbaneHospital, Brisbane, Australia
This video outlines the pre-operative, peri-operative and post-operative course of three super obese men weighing 335kg,285 kg and 275 kg. It shows two of them discussing their feel-ings prior to surgery and how they feel post-operatively.
It also includes some operative footage of the third of thesesuper obese men.
The purpose of the video is to highlight the great benefit thateven the massively super obese can derive from morbid obesitysurgery. Laparoscopic placement of a BioEnterics Lapband inall three cases.
111. LAPAROSCOPIC GASTRIC BYPASS WITH MANUALANASTOMOSIS.Antonio Cascardo, Silvio Albarracín, Adrian Alvarez. IMETCO(Multidisciplinary Institute Specialized in the Treatment and theSurgery of Obesity).
After Higa K. publications, we have assisted to a very impor-tant evolution of the Laparoscopic Gastric By-pass Surgery. Ourtechnique is done through the following steps: Confection ofGastric micropouch of 20 cc, with 45 articulated cutting linearendosuture (Ethicon).Enteral section at 20 cm of angle of Treitz.Entero-enteroanastomosis with manual closing of enteral open-ing, of one to two meters depending on the obesity of thepatient.The retrogastric, transmesocolonic handle is increased.Manual Gastro-enteral Anastomosis in two planes, with gaugedstoma of 12 mm. Fixation with two sticks of anterior face ofstomach to peritoneum, repaired with titanium clips.
The micropouch allows us to have a strict restrictive com-pound. The manual suture with narrow stoma, a good retainingwith less possibility of stances, shorter surgical time, safe andnotoriously cheaper anastomosis.
The preparation for a gastrotomy seems to us extremelyimportant in case of fistulae (for enteral feeding and disfunc-tionalize) or in order to allow the future study of the residualstomach.
112. IMPLANTABLE STIMULATOR (IGSTM) FOR TREAT-MENT OF SEVERE OBESITY: INITIAL EXPERIENCE INGREECE.J. Melissas, G. Schoretsanitis, J. Michalakis, H. Sanidas, G.Georgopoulou. Bariatric Unit, Dept.Surgical OncologyUniversity Hospital, Heraklion Crete Greece.
Background: The implantable gastric stimulator, is a recentinvestigational method for treatment of clinically severe obesity.This study describes the initial experience from the first implan-tations, in Greece.
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Methods: 5 morbidly obese female patients underwentimplantation of gastric stimulator. Mean age was 28.6 yearsmean weight was 121 kg and mean BMI 42.9. The implantationwas performed under G.A. The lead was implanted laparoscop-ically using 4 ports in a high position of the lesser curve.Simultaneous gastroscopy was performed to exclude lead pen-etration into the gastric mucosa. We used two grasping instru-ments to hold the stomach. The lead was fixed to the anteriorstomach wall by 2-0 silk stitch. The electric pulse generatorimplanted simultaneously in the subcutaneous tissue of theabdominal wall anteriously to the left rectus sleeth and securedin place with the application of a single silk No 0 stich.
Results: Mean implantation time was 50 min. Simultaneouslygastroscopy revealed penetration of the lead into the stomach inone patient. The lead was then replaced without further conse-quences.No serious complications intra or postoperatively wereseen. All patients recovered well and left the Hospital the firstpostoperative day.
Conclusions: From the technical point of view, implantation ofthe gastric stimulator (IGSTM ) is a simple technique. Providingthat this new method will prove its efficacy in reducing bodyweight, it will be a very good tool for management of clinicallysevere obesity.
113. THE USE OF A NITINOL U-CLIP (COALESCENTSURGICAL INC) FOR ADVANCED LAPAROSCOPICPROCEDURES INCLUDING GASTRIC BYPASS.Marina S. Kurian, MD, Valavanur Subramanian, MD, Mitchell S.Roslin, MD. Department of Surgery, Lenox Hill Hospital, NewYork, NY, USA
Nitinol, which is a combination of nickel and titanium, hasseveral unique properties. These include favorable handlingcharacteristics and the ability to return to it’s prefabricatedshape. These properties have been utilized for medical applica-tions in the central nervous system and coronary stents. A niti-nol clip (U -CLIP, Coalescent Surgical Inc) has been recentlyintroduced for minimally invasive cardiac surgery. The clip hasthe appearance of a more rigid suture with memory and isplaced with standard instrumentation. After placement, the clipis deployed with a simple squeeze of the needle holder, thuseliminating knot tying. Clips with larger circumference (.080-.120in) have been developed for gastrointestinal attachments.The advantage of the nitinol clip is that it offers the flexibility ofsuture, combined with easy handling and rapid deployment withno additional instrumentation.Tissue incorporation is similar tostaples since the exterior surface, titanium oxide, is the same.In the video, we will show a novel technique for suturing withapplication for purely laparoscopically hand-sewn or combina-tion stapled/ sutured anastomoses with the U-Clip for gastricbypass.Additionally, video showing the clinical use of the clip invascular attachments will be shown. Potential applications forlaparoscopic surgery will be discussed.
114. LAPAROSCOPIC LONG VERTICAL GASTRIC STA-PLING ± SLEEVE GASTRECTOMY FOR THE TREATMENTOF MORBID OBESITY.Michael J McMahon, Simon PL Dexter, George Delibaltadakis.Leeds Institute for Minimally Invasive Therapy, The GeneralInfirmary, Leeds, UK
Background: Long vertical gastric stapling (the Magenstrasseand Mill operation) has been the standard gastric restrictive pro-cedure used for morbid obesity in our institution over the last 10years. At laparoscopic surgery access to the short gastric ves-
sels and the use of the harmonic scalpel enable the redundantfundus and gastric body to be safely removed.The sleeve gas-trectomy leaves a narrow gastric tube between the gastro-oesophageal junction and the antrum
Content: This video demonstrates the technique of laparo-scopic sleeve gastrectomy. The patient preparation and portpositions are shown.The greater curve and fundus of the stom-ach are mobilised using the harmonic scalpel, within the gastro-epiploic arcade, with division of the short gastric vessels. Thelesser sac is freed of adhesions and the gastric tube fashionedover a 32Ch bougie, using an angled EndoGIA (USSC) stapler.The staple line is oversewn with a continuous suture and theexcised gastric body removed within a tissue retrieval sac.
115. TECHNICAL STRATEGY OF HALS-GASTRIC BYPASSFOR THE SUPER/SUPER OBESE PATIENT.Isao Kawamura MD1, Kazuma Yamazaki MD1, Masaaki KodamaMD1, Okamichi Morikawa MD1, Yukimasa Miyazawa MD2,Takenori Ochiai MD2. JA Marronnier MedicalCenter,Shimotsuga General Hospital1 Department of Surgery,Chiba University School of Medicine2
Because of insufficient clinical-results of vertical banded gas-troplasty or K-gastroplasty for the patient of super/super obesity,we have been performing HALS (hand assisted laparoscopicsurgery) roux-en Y gastric bypass for them. Although we havehad excellent effect of body weight reduction of them after theoperation, occasionally we have had to encounter the difficultiesduring and immediately after the operation.The most hazardouscomplication of the operation is the occurrence of the leakageof anastomosis between small gastric-pouch and roux-en Ylimb.
In order to prevent the insufficient anastomosis of them andto extend this operation in general, we have contrived to set-upthe Anvil of 21mm CEAA (circular stapler) in the small gastricpouch,that must be one of the key to overcome it. We routinelyinsert it with special guide-tube orally with the contrivance toaccomplish the anastomosis.
We have performed this operation for three super/superobese patients,which had different post operative course withthese contrivances.
116. GASTROENTERIC BY-PASS: MODIFICATION OF THETECHNIQUE.Antonio Cascardo, Silvio Albarracín, Adrian Alvarez. IMETCO(Multidisciplinary Institute Specialized in the Treatment and theSurgery of Obesity).
Since 1967, when Mason and Ito described the gastroentericBy-pass as a bariatric technique, it has gone through manymodifications until it became the “The Standard Gold” of thesurgeries and the favorite for the experienced surgeons.Fobi in 1991 and then Capella add variants so as to decreasethe reservoir of the stomach, to regulate the stoma of exit andthe worry for the study of the residual stomach, adding a ruledgastrotomy.
In 1994 Wittgrov and Clarke published 5 cases of By-passthrough laparoscopic way, complex technique with a hard curveof learning. The illnesses of the residual stomach described inthe literature are severe: peptic ulcers and gastric cancer,among others. There are publications of techniques with ecog-raphyc guides to make percutaneous gastrotomies for the studyof residual stomach post by-pass.
The Laparoscopic technique as well as the Laparostomic oneof IMETCO, makes a gastric micropouch of 20 cc with articu-
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lated 45 endocutter, or 75 TLC (Ethicor); manual gastroen-teroaostomosis leaving an exit stoma of 1,2 cm. measured andgauged. Entero-entero anastomosis from one to two meters ofthe angle of Treitz, according to the obesity and the alimentaryhabits of the patient.
We conclude every operation fixing the anterior face of theresidual stomach with two sticks to the peritoneum repaired withtitanium clips.This way, we leave a future percutaneous gastro-tomy of an easy completion in an XR room.
If necessary, in the immediate post-operation for decompres-sion, if there is an acute gastric dilatation, or so as to disfuc-tionalize Gastroenteral anastomosis and to feed in an enteralway in case of fistula.
In the distant post operation, if necessary, it can be done forthe excluded gastroenteral tractus study. This way, the inconve-nience of systematic gastrotomy is avoided, which is unneces-sary in the majority of the patients, and the use of more complextechniques to obtain it is also avoided.
117. A COMPARATIVE STUDY BETWEEN FOUR BARIATRICPROCEDURES: IS THERE AN IDEAL PROCEDURE YET?Khaled Gawdat, MD. Ain-Shams School of Medicine, Cairo,Egypt.
Background: Many surgical options are currently available fortreating morbid obesity. We present the results of a comparativestudy between four different bariatric procedures with < 55months of follow up.
Methods: 340 morbidly obese patients where operated uponby a single surgeon with a follow up period of £ 55 months.Themean age was 33.9 years and 78.1% of our patients werefemales. The mean weight was 147.4 kg with a mean BMI of55.3kg/m2 and the mean EBW was 88.7 kg. For every patient,one of four procedures was chosen, either a vertical bandedgastroplasty (VBG) (N: 225), or Laparoscopic adjustable gastricbanding (LAGB) (N: 40), or Roux-en-Y gastric bypass (RYGB)(N: 56) or a bilio-pancreatic diversion with duodenal switch(BPD&DS) (N: 19). Procedure choice was based on preopera-tive age, weight, eating habits, bowel habits and economicalstatus. Outcome of the 4 procedures was compared in terms ofcomplications, weight loss, co-morbidity improvement and lifestyle.
Results: At 24 months postoperatively LAGB patients lost31% of excess weight (%EWL), VBG patients lost 69% EWL,RYGB patients lost 72%EWL and BPD&DS patients lost78%EWL. Failure to reach 40% EWL occurred to 42.5% of theLAGB patients and to 16.6% of the VBG patients and to 1.7% ofthe RYGB patients and 0% of the BPD&DS patients. LAGBpatients had a 12.5% complications rate (2 band erosions, 2port dislocations, 1 port infection) with a 10% re-operation rate,VBG patients had an 8.9% complications rate (12 incisional her-nias, 3 pouch obstruction, 1 mesh migration, 1 gastritis) with a5.6% re-operation rate. RYGB patients had a 10.7 % complica-tions rate (4 incisional hernias, 1 anemia, 1 intestinal obstruc-tion) with a 7.6% re-operation rate. BPD&DS patients had10.5% complications (2 incisional hernias) with no re-opera-tions. Solid food intolerance occurred in 30% of the LAGBpatients and in 17.7% of the VBG patients and in 5.7% of theRYGB patients, while none of the BPD&DS patients had foodintolerance.
Conclusion: There is no single procedure that works for allpatients but there is an ideal bariatric procedure for everypatient. The choice of procedure should be individualized perpatient with super-obese patients, sweet eaters and female
patients above 50 being submitted to RYGB or BPD rather thanLAGB or VBG. Adjustable gastric banding gave the lowestweight loss rate of all procedures and was associated with asimilar complications rate as compared to other procedures.VBG, RYGB, BPD&DS gave good weight control with a lowcomplications rate except for the incisional hernia rate that wascommon after open procedures.
118. COMBINED SURGERY FOR MORBIDLY OBESE WITHREFLUX ESOPHAGITIS.Alaa Abbass S. Moustafa, Essam Abd el Gelil. Ain ShamsUniversity and Ahmed Maher Teaching Hospital, Cairo, Egypt.
Background: Sliding hiatus hernia and reflux oesophagitis arecommon among the morbidly obese. There is a risk of increas-ing the peptic oesophagitis after gastric restrictive surgery. Toavoid denying indicated patients or facing the problem of dis-ease exacerbation after surgery, we investigated the combinedsurgery of antireflux and gastric restriction for morbidly obesepatients with reflux oesphagitis.
Methods: 30 patients( 22 females, 8 males) were treated sur-gically for morbid obesity and reflux oesophagitis between 1998and 2000. Toupet partial fundoplication combined with verticalbanded gastroplasty V.B.G.was performed . Median age ofpatients was 34 ( range 20-51), and preoperative median B.M.I.was 49 ( range 40-55 ). All operations were done by opensurgery.
Results: Operative time was 55-130 ( median 70 min). Noremarkable intraoperative or postoperative complications wereencountered. During follow-up satisfactory control of refluxoesophagitis was achieved . At one year mean weight loss was45 Kgm and mean excess weight loss was 60%. Median hospi-tal stay was 4 days.
Conclusion: Combined surgery is a good option for the mor-bidly obese with reflux oesophagitis. It is better than facing theproblem postoperatively to plan its management preoperatively.
119. ELECTROGASTROGRAPHY IN MORBIDLY OBESEPATIENTS.Francois van Dielen*, Freek Daams**, Bas de Cock*, Robert-Jan Brummer**, Jan Willem Greve*. Dept. of General Surgery*and Gastroenterology**, University Hospital Maastricht, TheNetherlands.
Background: Electrogastrography (EGG) is a new techniqueto study gastric myoelectrical activity (gma). The aim of thisstudy was to compare gma in lean and morbidly obese subjects(MO) and to investigate the effect of LapBand on gma in MO.
Methods: To determine gma, EGG was performed in 12 MO(age: 42.9 ± 13.0; BMI: 48.5 ± 5.7) preoperatively (preop) and12 lean (age: 27.8 ± 12.2 years; BMI: 21.8 ± 1.4). Next to this,EGG was performed in these 12 MO 3 months postoperatively(postop). Six electrodes were placed on the abrased skin. Afasting state recording of 30 min. was followed by a standardtestmeal and a postprandial recording period of 30 min. The fol-lowing EGG-parameters were determined in both fasting (f) andpostprandial (pp) state: dominant frequency (DFf/pp), dominantpower (DPf/pp), dominant power instability coefficient(ICf/pp=SD of DP/mean DP) and power ratio (PR=meanDPpp/mean DPf).
Results: ICpp significantly (p<0.05) decreased in MO com-pared to lean (MO: ICpp=0.24 ± 0.07; lean: ICpp=0.29 ± 0.06).DFpp significantly (p<0.05) increased in lean (DFf=2.86 ± 0.16,DFpp=3.03 ± 0.15) and MO (DFf=2.94 ± 0.17, DFpp=3.0 ±0.17). PR did not differ between MO and lean. After operation
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BMI decreased from 48.5 ± 5.7 to 43.6 ± 5.6 (p<0.01).DFpp sig-nificantly (p<0.05) increased from 2.99 ± 0.17 preop to 3.11 ±0.25 postop. Furthermore, a significant decrease of DPpp wasfound (preop: DPpp= 3242 ± 1736; postop: DPpp= 2038 ± 877;p<0.05). However, no significant difference was found for PR,DFf, DPf, ICf and ICpp in MO preop and postop.
Conclusion: This study showed differences in gastric myo-electrical activity between morbidly obese patients and lean.TheICpp in morbid obese subjects was significantly lower comparedto lean. Moreover, after LapBand DPpp decreased significantly.These findings might suggest lower contractile stomach activityin MO after a meal compared to lean, which even moredecreases after LapBand operation.
120. IS THE LAPAROSCOPIC REBANDING FOR POUCHCOMPLICATIONS AFTER LAPAROSCOPIC GASTRICBANDING THE RIGHT CHOICE?M. Weber1; M. K. Müller1; F. Horber2, L. Krähenbühl1, R. S.Hauser3. 1UniversityHospital Zürich; Clinic for Visceral Surgery,Zürich, Switzerland, 2Klinik Hirslanden, Zürich, Switzerland,3Consultant for Nutrition, Zürich, Switzerland
Background: Thousands of gastric bandings have been per-formed during the last years in Europe. There are increasingdata that in the long-term follow-up an incidence of pouch com-plications of more than 15% must be expected. These compli-cations can be treated by debanding, rebanding or otherbariatric procedures. The aim of this analysis was to evaluatethe efficiency of rebanding after primary failure of the gastricbanding.
Methods: Between 1997 and 2000 the data of 26 cases witha laparoscopic rebanding have been assessed prospectively.
Results: Patients with a pouch complications had either aninsufficient weight-loss or the obstruction lead to vomitus andfood intolerance. After an interval of 605 days (range 69-1400)patients were operated again. Then, a new band had to beimplanted or the preexisting band was repositioned and refixedagain. Only in one case we had to convert to open surgerybecause of a bleeding (conversion rate: 3.5%). The mean hos-pital stay was 4.4 days (2-11). The mean Body-Mass-Index(BMI) before primary banding was 45,9 kg/m2, the fat mass was63.3 kg. The mean BMI before rebanding was 38 kg/m2, themean fat mass was 44.15 kg. After rebanding with a follow up of592 days (35-1386) we found a mean BMI of 38,8 kg/m2, and amean fat mass of 47.4 kg.
Conclusions: The laparoscopic gastric rebanding can be per-formed safely in so called pouch complications after laparo-scopic gastric banding. However, in our series the laparoscopicrebanding did not result in a further weight loss. Therefore, theindication for rebanding in case of pouch complications has tobe questioned, since the underlying cause (e.g. eating disorder)might still be present.We recommend to consider other surgicalprocedure, such as laparoscopic gastric bypass.
121. LAP-BAND EROSION: INCIDENCE AND A WAY OFTREATMENT.Erik Niville. Ziekenhuis Oost Limburg Genk, Belgium
Background: Laparascopic adjustable gastric banding is aneffective and safe surgical treatment for morbid obesity.Migration of the band through the stomach wall is a well-knownlate complication that requires band removal. After bandremoval, there is usually a request for a second bariatric proce-dure.
Methods: 333 patients were followed for at least two years
(mean follow-up 43 months) after a Lap-Band procedure.Erosion cases were studied retrospectively.
Results: Five patients (1.5%) developed erosions.Each time,laparoscopic removal of the Lap-Band was carried out shortlyafter the diagnosis.No postoperative complication occured.Thefirst four patients have received a new Lap-Band four to fivemonths after removal. For the first patient conversion fromlaparoscopy to laparotomy was required, and for the other threepatients the procedure was carried out laparoscopically. Again,no complications occured and the four patients are doing well17, 12, 11 and 9 months after the rebanding procedure respec-tively. Gastroscopy revealed re-erosion in none of the cases.
Conclusion: Lap-Band erosion is a bothersome late compli-cation after laparoscopic adjustable gastric banding proceduresand requires band removal. This can be done laparoscopicallyin a safe way. There is usually a request for another bariatricprocedure and rebanding is a feasible and safe option. In orderto determine the value of this treatment, a prospective study isbeing conducted which involves following 10 to 20 rebandederosion patients for three years with routine endoscopy at one,two and three years after rebanding.The aim is to gain answersto questions as to 1. the effect on patients’ weight, 2. whethererosions will redevelop and 3. whether other problems willoccur.
122. LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING:PERSONAL EXPERIENCE.Marcello Lucchese, MD, Andrea Valeri, MD, Giovanni Cantelli,MD, Ingrid Paulin, MD, Saverio Reddavide, MD, DomenicoBorrelli, MD. Dept. of Gen. and Vasc. Surgery, Policlinico diCareggi, Florence, Italy
Background: Laparoscopic adjustable silicone gastric band-ing (LAP-BAND®) may perhaps provide the best results withminor risks for weight loss, especially if performed bylaparoscopy. The aim of this study is evaluate short and long-term complications observed in pts. operated on bylaparoscopy.
Methods: 302 patients, aged 16-62 years, with a mean BMI of48.5 kg/m2 (36.5-70.8) were operated on since 1992 in our insti-tution, 117 of which by laparotomic approach (including 72 pts.by original Kuzmak’s banding) and 185 by laparoscopy. In 6(3.7%) of these last cases we had to convert to laparotomy. In 8pts. we associated colecistectomy and in 2 pts. hiatoplasty.
Results: Regarding our 185 laparoscopic operations, periop-erative complications were stomach wall perforation recogna-tized and sutured intraoperatively in 2 pts. (1.2%), p.o. pneu-mothorax in 2 pts. (1.2%) and pulmonary embolism respondingto medical therapy in one patient (0.6%). The most commoncomplication in the laparoscopic series was irreversible pouchdilatation which occurred in 7 cases (3.1%) always requiringreoperation. It consisted in band removal due to pt’s choice bylaparoscopy in 3 cases, laparoscopic band repositioning in 1case and band removal associated to DBP with stomachpreservation in 3 pts. Moreover one patient wanted to removethe band by laparoscopy for weight loss absence and anotherone required band removal with classical DBP for weight regain.In one patient (0.6%) we observed band migration (erosion) atfour months from operation presenting a port site sepsis andrequired band removal. In 6 pts. (3.7%) we observed the con-necting tube rupture which required a laparoscopy. This obvi-ously advised us to change the port site in the last cases. Inother 5 cases we noted a port leakage and we changed it.
Conclusions: LASGB seems to be a safe procedure in the
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treatment of severe obesity with a low rate of complications butit requires a very strict patient follow up and a good patientselection by a multidisciplinary team.
123. ADJUSTABLE SILICONE GASTRIC BANDING FORREVISION OF FAILED GASTRIC BARIATRICPROCEDURES.Sholmo Kyzer, Aznat Raziel, Ofer Landau, Alexander Matz, IlanCharuzi. Department of Surgery “B”, E. Wolfson Medical Center,Holon, Israel
Background: Revision of gastric bariatric operations is some-times technically difficult and may fail to achieve prolongedweight reduction. The use of the adjustable silicone gastricbanding (ASGB) offers a new approach for these revisions.
Methods: ASGB was performed as a revisional procedure on37 patients whose initial bariatric procedures were as follows:silastic ring vertical gastroplasty (21), gastric bypass (12), hori-zontal gastroplasty (3) and vertical banded gastroplasty (1).
Results: The length of the procedure varied from 55 to 145minutes (mean 83 minutes). Intraoperative complicationsincluded two fundic tears which were sutured without any post-operative sequelae.Five patients needed reoperation during thefirst postoperative year due to gastric volvulus (1), tubing tear(1) and development of postoperative ventral hernia (3). BMI fellfrom 44.8 ± 8.07 to 33.4 ± 6.9 Kg/m2 for patients reoperatedwith BMI higher than 35 Kg/m2 and from 29.2 ± 3.32 to 25.4 ±2.8 Kg/m2 for patients operated with BMI lower than 35 Kg/m2.
Conclusions: ASGB can be performed for revisions with anacceptable complication rate and postoperative weight reduc-tion.
124. QUALITY OF LIFE FOLLOWING LAPAROSCOPIC GAS-TRIC BANDING FOR OBESITY.Reyad Al-Ghnaniem*, Andrew Dettrick§, George Fielding§,Ameet G Patel*. *King’s College Hospital, London, UK. §WesleyMedical Centre, Brisbane, Australia
Background: To assess the impact of laparoscopic gastricbanding (LGB) on the quality of life of obese patients.
Methods: A validated questionnaire (IWQOL) was sent to 37patients who underwent LGB and 21 consecutive obesepatients who were accepted for LGB (controls). The question-naire was composed of 8 parts (74 items) and covered health,social/interpersonal, work, mobility, self-esteem, sexual life,activities of daily living and comfort with food.The patients’bodymass index (BMI) was recorded before surgery in the LGBgroup and at the time of the study in both groups.
Result: Twenty-one (57%) LGB patients and 21 controls(100%) responded to the questionnaire.The patients’ character-istics were similar in both groups. The mean BMI of the LGBpatients before surgery and for controls at the time of the studywas 45.1 (40.5-49.8, 95% CI) and 42.6 (38.8-46.4, 95% CI),respectively (P= 0.473). The mean time since LGB was 21.3months (19.1-23.6, 95% CI). During the follow up period therewas a reduction in excess body weight (EBW) of 40.8% (31.5-50.2, 95% CI). The differences in quality of life scores are sum-marised in the following table.
LGB Controls
Parameter mean (95% CI) mean (95% CI) PHealth 3.7 (23.-51) 6.76 (5.86-7.66) 0.001*Social and inter-
Conclusions: LGB results in significant EBW loss andimproves quality of life in the medium term.
125. INTRAGASTRIC BALLOON TECHNIQUE FOR THETREATMENT OF SEVERE OBESITY: SHORT-TERM ANDMID-TERM FOLLOW-UP OF THE FIRST 52 PATIENTS INARGENTINA.Cormillot Alberto, LaRegina Rosana, Pozzoni Carlos, DizAlejandro, Argonz Julio, Fuchs Analia. Clínica de Nutrición ySalud, Buenos Aires, Argentina
Background: Severe obesity is a chronic desease that is verydifficult to treat. Surgery to promote weight loss by restrictingfood intake is an option for patients with BMI>35 or importantco-morbidities. Among the different bariatric interventions,Intragastric Balloon Treatment is a minimally invasive alternativethat do not requires profound anesthesia nor long inactivity.Theplacement, the volume injection and the removal of the IB areperformed endoscopically. The action of the IB is to partially fillthe stomach, therefore inducing satiety.
Methods: From Oct. 2000 to March 2001, the first 52Intragastric Balloons (IB) were placed in Argentina. Obesepatients (29 women(w) and 23 men (m)) were mostly recruitedfrom the Cormillot Network for the Treatment of Obesity, accord-ing to indications and restrictions given by BioentericsCorporation, after thorough clinical, biochemical and psychiatricevaluation. All patients had failed repeated weight loss pro-grams and had a medical condition that would benefit fromweight loss.They had been well-informed on the procedure anda consent form was signed. Expectations and follow-up plan(diet, physical activity and contacts) were discussed in advance.Procedure characteristics: Device placed by direct endoscopicvisualization.The ballon is filled with variable volumes of salineand Methylen Blue to detect any leakage, in order to individual-ize patient treatment(450 to 600 cc).It has a self-sealing valveand a radiopaque valve cap.
Results: Intervention time was 8 to 20 min. under mild seda-tion. with Medazolan.Preoperative BMI were 35 to 53 for w and38 to 67 for m. Gastroscopic findings were 4 gastritis gradeI(2diagnosed asHelychobacter Pylory later) and 1polip(benign).Patients were able to walk to the recovery room andhad a mean hospital stay of 2 ± 1days.Immediate complicationswere vomits (80%), nausea (90%in w and 20%in m) epigastricpain (55%), heartburn(40%), meteorism (15%).Five patientsdecided to remove the IB According to the date of implant,mean BMI change for w and m was -6 and - 4 in 6 months, -3.3and -3.2 in 4 months and -3 and -2.4 in 2 months.At the lastvisit,patients were asymptomatic and continued losing weight.About 40% complied with post surgical contacts.
Conclusions: Although patient expectations had been widelydiscussed before balloon placement, they exceeded the weightloss actually achieved. More emphasis is to be placed on com-pliance with follow up visits and support groups. Preliminaryresults have been satisfactory, thus encouraging to continuewith IB placements.Second time placement of the balloon is afurther possibility for these patients.
126. BIOENTERICS INTRAGASTRIC BALLOON (BIB™) :
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RETROSPECTIVE ANALYSIS.D. Raemdonck*, P. Belva*, P. Rotsaert*, J.C. Lefebvre*, M.Takkiedine*, P. Vaneukem*, A. Bailly **. Department of DigestiveSurgery*, Department of Clinical Nutrition **, CHU Charleroi,Charleroi, Belgium
Background : Among the different available therapeutic toolsto reduce obesity, Intragastric Balloons have been used over the last two decades as a temporary device with various outcomes.To test the efficacy of Bioenterics Intragastric Balloon (BIB™) inobese patients at short, medium and long term.
Methods: Between November 1997 and September 2000, 63BIB™ were endoscopically placed in 55 female and 8 maleobese patients.The mean age was 34 (range 17-55). At admis-sion the mean weight was 111.2 kg (range 64-224 kg), themean BMI was 40.4 (range 30-80) and the mean excess weight(EW) was 49.6 kg (range 12-108 kg). All patients were evalu-ated preoperatively by a multidisciplinary team composed of adietetician, an endocrinologist, a bariatric surgeon and a psy-chiatrist. BIB™ insertion was proposed to patients with BMIbetween 30 and 40 because they did not match the inclusioncriteria for a restrictive bariatric surgical procedure, to patientswith a BMI between 40 and 50 who choosed personally theintragastric balloon and to patients with a BMI over 50 in orderto loose weight before getting a more definitive bariatric surgicalprocedure. Comorbidity factors included 9 hypertension, 3 dia-betes mellitus, 2 ischaemic cardiomyopathy, 2 hypercholestero-laemia and 1 severe lumbar arthropathy. Upper GI endoscopywas achieved in each case under general anaesthesia and theballoon was filled with 500 to 800 ml of saline after insertion.Patients were discharged from the hospital 3 days post-op andwere reviewed clinically at different time intervals thereafter. Aretrospective analysis of their outcome has been undergone.
Results: 26 patients were reviewed after 1 month; their meanexcess weight loss (MEWL) was 12.1% (range–3-25%). 41patients were reviewed after 2 to 3 months; their MEWL was19.5% (range–6-41.5%). 34 patients were reviewed after 4 to 6months; their MEWL was 28.5% (range–6-62.7%). 26 patientswere reviewed later than 9 months after the BIB™ insertion;their MEWL was 22.5% (range–11.6-60.6%).We observed onealimentary intolerance to the BIB™ which required its removal 1month after insertion. No major complication such as gastricerosion, upper GI haemorrhage or bowel obstruction appeared.23 balloons ruptured among which 14 passed in the stool onaverage at 9 months post-op (range 4-16 months), 2 were vom-ited at 6 and 7 months post-op and 7 were removed endoscop-ically on average at 10 months post-op (range 6-14 months). 7balloons were deliberately removed after a significant weightloss on average at 10 months post-op (range 7-15 months).
Conclusion: Despite a relatively poor follow-up rate, BIB™remains a safe procedure offering a moderate weight loss atshort and medium term to individuals lacking inclusion criteriafor a more definitive bariatric surgical procedure.A good indica-tion could be high-risk and superobese patients.
127. ARE INTRAGASTRIC BALLOONS USEFUL IN THEMANAGEMENT OF OBESITY?A. E. E. Elewaut. Department of Gastroenterology AZGroeninge, campus OLV, Kortrijk, Belgium
Background: Obesity can be treated with dietary manage-ment, behavioral modification, medical therapy, jaw- wiring and/or surgery. Dietary management and behavioral modificationare safe but in many patients unsuccessful.Intragastric balloonsare since 1979 used as help for the non-surgical aproach of the
treatment of obese patients.With the first balloon-types a lot ofcomplications were mentioned with negative publicity. Newerballoons were developped: round shaped, smooth surface,radio-opaque, 6 month life, saline-filled.
Methods: In 84 obese patients (61 females, 23 men), meanage 37,6 years (14-58 y) with a mean BMI of 38 (25-71) an intra-gastric balloon was placed endoscopically in the stomachtogether with a diet regimen.
Results: In 76 patients 1 balloon was placed, in 5 patients 2balloons and in 3 patients even three balloons. In 8 patients theballoon had to be removed earlier because of intolerance.Fourpatients had a severe complication:one deshydratation, 2 angu-lar ulcers, one obstruction.In 45 patients the balloon wasremoved endoscopically, in 9 patients there was a spontaneousevacuation, in 9 patients the balloon is still present and 21patients are lost to follow-up. After 6 months there was a meanreduce of the excessive weight of 45%, after 9 months even56%. The mean BMI deminished from 38 tot 32.7. There was amean weight loss of 15 kg after 6 months, 20 kg after 9 months.
Conclusions: Intragastric balloons can induce an effectiveweight loss in a highly motivated subpopulation of obesepatients. It gives the opportunity to learn an effective diet regi-men. The reduced maintenance is however difficult. It can beused in extreme obese patients before surgery.
128. THE NEW INTRAGASTRIC BALLOON (BIB): A FRENCHEXPERIENCE OF 23 CASES, WITH ADJUNCTION OF AHIGH-PROTEIN DIET.Jerome Dargent, MD, Laurence Poulain, Dietitian. Polycliniquede Rillieux. 941, Rue Capitaine Julien. France
Background: The intragastric balloon (BIB) is now widelyused in Europe, either in morbid or in severe obese.The preop-erative use in morbid obese has not been an option in our expe-rience; we use to propose the BIB to patients with a BMI above30 and not eligible for bariatric surgery, and look for improve-ment of short-term results.
Methods: From April 2000 to January 2001, a newBioenterics balloon was implanted in 23 female patients in ourinstitution. Mean age was 41 (32-57). Mean weight was 83 kg(73-95), mean excess body-weight was 30 kg (20-38), andmean BMI 31,4 (30-38). All patients had a general anesthaesia.Patients were seen monthly post implant. When possible, ahigh-protein content diet was initiated from week 3 and main-tained until week 12 after implant.
Results: Mean weight-loss results after 6 months has been15 kg (5-27), and excess weight-loss 15% (10-66).Two patientsdid not tolerate the advised 500 cc inflation of the new BIB andhad it removed.This led us to inflate 450 cc to patients with BMIunder 35. The protein diet made it possible to increase weight-loss of an average 3 kg, but only 30% of the patients could con-tinue it from week 6 to week 12.
Conclusion: We believe that intragastric balloon is an inter-esting first-step procedure in treating severe or morbid obese. Astrict diet follow-up is utterly requested; a high protein contentdiet is likely to enhance short-term weight-loss.
129. TREATMENT OF MORBID OBESITY WITH INTRAGAS-TIC BALLOON (BIBTM) IN ASSOCIATION WITH DIET.Santo Bressani Doldi, G. Micheletto, M. Perrini, M. C. Librenti*,S. Rella*. Cattedra di Chirurgia Generale dell’Università degliStudi di Milano-Istituto Clinico Sant’Ambrogio (Direttore: Prof.S.B.Doldi); Centro per la Farcomacoterapia delle MalattieNutrizionali e Metaboliche “E. Genovese e R. Klinger” (Direttore
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Scientifico: Prof. S.B.Doldi) *Unità di Malattie Metaboliche -Istituto Clinico San Siro, Milano, Italy
Background: In our Centre of bariatric surgery since march1998 we have used the intragastric balloon (BioEntericsIntragastric Balloon BIB®) associated with restricted diet for thetreatment of obesity and morbid obesity.Here we refer the mostsignificant results of our experience.
Methods: Since march 1998 we placed 240 BIB in 217 obeseand morbidly obese patients : 59 were male and 158 female.Mean age: 42.2 years (19-70); mean weight: kg 117.4 (67-229);mean BMI: 41 (29-81). 22 patients (13 female and 9 male) hada second BIB and one patient underwent a third balloon. All thepatients were submitted to blood and instrumental screening.After 24 hours of liquid diet the patients were subjected to endo-scopic placement of BIB in general anesthesia with orotrachealintubation. In 147 patients the BIB was removed after 4 months;a new pattern of balloon, introduced in march 2000, allowed tomaintain the BIB for 6 months in 93 patients.The mean balloonfilling was 531 ml (350-700) of saline with 10 ml of methylene-blue. The patients were given a balanced diet of 1000 Cal perday, with the temporary addition of omeprazole, vitamins andoligominerals. Follow-up involved a monthly check-up withrepeat routine blood tests and weight controls. If symptomssuch as nausea or vomiting are reported or there is weight gain,the patient is subjected to an abdominal ultrasound or X-ray.Removal of the balloon was performed under general anesthe-sia with intubation.To value the efficacy of BIB + diet treatmentvs. diet alone, we compared for 6 months 42 obese patients (32f, 10 m) treated only with 1000 Cal diet (Group A) with 31 obesepatients (24 f, 7 m) subjected to BIB + 1000 Cal diet (Group B).The patients were homogeneous for sex, age and weight. Thetwo groups continued 1000 Cal per day diet for further 12months.
Results: Mean weight loss was 14.5 kg (2-35); the meanreduction in BMI was 5.1 (0.3-11.2). Mean male weight loss was17.4 kg and female was 12.6 kg; the mean weight loss in obesepatients with BMI > 40 was 16.4 and in those with BMI < 40 was11.3 kg. The main complications observed were: balloon intol-erance with persistent vomiting and electrolyte unbalance: 5%;insufficient weight loss (<10 kg): 7.5%; BIB deflation: 2.9%. Thecomparison of group A with group B showed: at 6th month meanfemale group A weight loss was 11.9 kg (mean reduction ofBMI: 4.7), mean male was 16.4 kg (mean reduction of BMI: 5.6);in group B mean female weight loss was 15.5 kg (mean reduc-tion of BMI: 5.6) and mean male was 21.1 kg (mean reductionof BMI: 6.8). At 12th month group A female had mean weightloss: 15.3 kg (mean reduction of BMI: 6) and male had: 19 kg(mean reduction of BMI: 6); group B female weight loss was11.2 kg (mean reduction of BMI: 3.9) and male was 24.2 kg(mean reduction of BMI: 8).
Conclusion: 1) the weight loss trend was much better in malepatients; 2) the weight loss trend was much better in patientswith BMI > 40; 3) BIB + diet produced greater weight loss inshorter time vs. diet alone; 4) BIB complications were poor andeasy to cure; 5) the most correct clinical indication for BIB ther-apy should be in morbidly male obese patients as preparatorytreatment before bariatric surgery with the objective of reducingunacceptable operative risk; 6) after BIB removal, bariatricsurgery must occur as soon as possible; 7) in patients with obe-sity-related complications before surgery; 8) in patients withsevere cardiorespiratory alterations who will never be subjectedto bariatric surgery but who must obtain a rapid, considerableweight loss; 9) in grade I obesity and in the overweight, only in
selected cases and into multidisciplinary approach.130. PRELIMINARY REPORT ON SURGICAL INTERVEN-TION ON PATIENTS WITH BMI>32 BUT<40 WITHOUT LIFETHREATENING COMORBIDITIES.MAL Fobi, MD F.A.C.S. Center For Surgical Treatment OfObesity, Tri-City Regional Medical Center, Hawaiian Gardens,USA
Background: Surgical intervention is currently indicated forpatients with BMI>40 or >35 with life threatening comorbidities.Patients with BMI of 35-40 without these comorbidities do notonly have the increase propensity to develop them but sufferfrom the same psycho-socioeconomic consequences as thosewith BMI>40. These patients do not respond any better to non-surgical treatment of their obesity.The question has been raisedoften why not offer them surgical intervention. A study wasundertaken to find out.
Method: A study was carried out to determine the outcome ofsurgery on patients with BMI>32 but<40 without life threateningcomorbidities but with either psychological, economic or socialimpairments affecting their quality of life. The approval of ourHospital Internal Review Board was obtained and fifty patientswere entered into this study. In addition to the routine evaluationfor surgical intervention these patients were required to have theapproval of their primary care physician, be seen pre-opera-tively by a psychiatrist and have a member of the family or avery close friend present at the time of the discussion of theoperation risk and follow up requirements.They committed to atleast a five years follow-up.They were to be self-paying patients.The transected silastic ring vertical banded gastric bypass wasused.
Results: Fifty patients were entered into the study betweenMay 1st.1999 and Sep. 30th 2000. Most of them were self-paybut there were some who were able to obtain coverage throughtheir insurance companies. There were forty-eight women andtwo men. There were no peri-operative complications nordeaths.The hospital stay was an average of 3.7 days. Follow-uphas been from 9 months to 2 years. The weight loss has beenexcellent.
Conclusion: Surgical intervention can be extended to patientswith BMI 32-40 without life threatening comorbidities but withpsycho-socioeconomic ramifications. Preliminary results arevery promising. Long term follow-up and comparison to otherbariatric patients are planned.
131. TISSUE ADHESIVE FOR BARIATRIC SURGERY.Alan C. Roberts*, Stever Pollard*. *Academic Surgical Unit,University of Hull Medical School, England; **Department ofSurgery, St. James’s Hospital, Leeds, England
Background: Over a period of several centuries the union andclosure of human tissue has been achieved by means of needleand thread. Historically many types of suturing materialsemployed have met with varying success. Primarily there havebeen natural products such as cotton wool, fibre, linen and ani-mal sinews. In modern surgical science synthetic materials suchas nylon, dacron and various composites have gained impor-tance.The culture and convention of wound closure by suturinghas been the standard method for generations of surgeons.During the past 25 years there has been a steady increase ininterest in replacing and augmenting conventional sutures byadhesive bonds.There are several reasons for this clinical inter-est. First the potential rapidity with which tissue union can beachieved.Also the ability of bonding substrate to effect completetissue closure preventing seepage of body fluids. There is also
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an added advantage of forming bonds without deformation ofthe tissue.The possibility for improvement in the repair of tissueaffected by age and disease and where suture methods are dif-ficult and the ability to effect tissue closure in inaccessible areasof the body by laparoscopic surgery.
Methods: The surface phenomena found in novel formula-tions of cyanoacrylates have shown considerable possibilities insurgical practice.
Results: The rapid polymerisation of these monomers whenapplied to moist tissue surfaces have shown the ability to bondhuman tissue effectively. They have also been found to act asfast and effective haemostatic agents and to achieve a mildanaesthetic effect in topical application.
Conclusions: The development and use of tissue adhesivesynthesised in the laboratory presents an inventory sterileadhesive with an effective use across the field of surgery.Cyanoacrylates have proved an effective sterile liquid suturesystem. Our experience of one N-butyl cyanoacrylate, Indermil,will be described and its potential demonstrated in BariatricSurgery.
132. CORRELATION BETWEEN FAT DISTRIBUTION,HYPERLIPIDEMIA, DIABETES AND CORONARY HEARTDISEASE IN MORBIDLY OBESE PATIENTS.Anna Maria Wolf, Burkhard Kortner, Hans Werner Kuhlmann,Ulrike Beisiegel*. General Surgery, Evangelisches undJohanniter Klinikum Duisburg/Dinslaken/Oberhausen gGmbH,Germany, *Medical Clinic, University Hospital Hamburg-Eppendorf, Germany
It has been recognized that patients with a BMI < 40 kg/m2
with excess abdominal visceral fat have more risk factors forcoronary heart disease than those with excess subcutaneousabdominal fat. We were interested if these risk factors are thesame for patients with a BMI > 40 kg/m2. Performing bariatricsurgery on morbidly obese patients we had the opportunity tomeasure the subcutaneous fat layer. We differentiated betweenpatients with excess subcutaneous abdominal fat and excessabdominal visceral fat. A third group represented patients with acombination of both.
We divided our patients into females (n=318) and males(n=76) and analyzed the above mentioned three groups differ-ently. Comparing males with excess abdominal visceral fat(n=52) with those who had a combined fat distribution (n=22) wefound a significant effect on serum lipid levels. Triglycerideswere significantly higher in patients with excess abdominal vis-ceral fat (284 mg/dl vs 197 mg/dl, p=0.03) than those with acombined abdominal fat distribution and HDL was lower (34mg/dl vs 38 mg/dl, p=0.08). The lipid pattern of elevated triglyc-erides and low HDL is known to be a high risk factor for coro-nary heart disease. In female patients we did not see such ahigh risk lipid profile but there are significant differences in BMIand WHR. Female patients with excess abdominal visceral fat(n=62) have a higher BMI and WHR than those with excess sub-cutaneous abdominal fat (n=31) as well as those with a combi-nation of both (n=225).
In all patients with excess abdominal visceral fat leptin wasfound to be significantly lower than in the other two groups.Thisdifference in leptin does not correlate to differences in BMI. If weanalyze the known risk factors in our patients we found a higherpercentage of coronary heart disease and diabetes in patientswith excess abdominal visceral fat. As to diabetes fasting glu-cose was only significantly higher in the females with excessabdominal visceral fat (123 mg/dl vs 104 mg/dl, p=0,00007).
The knowledge of risk factors as shown here should aid thedecision as to recommend a bariatric procedure to morbidlyobese patients.
133. FOUR-YEAR EVALUATION OF THREE SURGICALTECHNIQUES.R. Alvarez-Cordero, V. E. Aragón, R. J. Montoya, A. O Sandoval,D. A. Toledo. Hospital Angeles del Pedregal, México City,México.
In order to compare the long term evolution of three surgicaltechniques performed in our Clinic of Weight Control andSurgical Treatment of Obesity, this study was done by analyzingthe obese patient condition, weight, fat percent, comorbiditiesand quality of life, before surgery, and one, two, three and fouryears after surgery. 52 patients were operated of a reinforcedgastric bypass (OGBP), 45 had silastic ring gastroplasty (SRG),and 47 gastric banding (LB). They all comply with the follow upconsultations, and most of them attended the support groupmeetings.
Patient’s condition: No hemodynamic or cardiopulmonaryproblems were noted in these series, regardless the patient’sweight or the surgical technique used.
Excess weight loss: OGBP patients excess weigth loss wasbetween 20 and 75% on year 1, 24 and 90% year 2, 22 and100% year 3 and 18 and 86% year 4. SRG patients excessweight loss was between 14 and 56% year 1, 19 and 72% year2, 14 and 78% year 3, and 14 and 74 year 4. LB patients excessweight loss was between 12 and 60% year 1, 19 and 72 year 2,15 and 100% year 3 and 18 and 83% year 4. These numbersgive an average of 42,68,73 and 72% for OGBP patients, 32,56, 66 and 62% for SRG patients, 38,60,68 and 69 for LBpatients.
Fat percent: initial average fat percent was 62 for OGBP, 65for SRG and 60 for LB patients, they lose fat and had on aver-age: OGBP 58,50,36,35 on succesive years, SRG 59, 42,40,42,and LB 60,45,35,34.There was a correlation between excerciseand fat percent improvement.
Comorbidities:High blood pressure:at four years, blood pres-sure was normal in 14 out of 23 OGBP patients, in 11 out of 19SRG patients and in 15 out of 29 LB patients.The use of insulinor diabetes medication was discontinued in 16 out of 31patients, 6 OGBP, 5 SRG and 4 LB patients; it was necessary tocontinue the medication in 7,4 and 4 patients.Sleep apnea wasrelieved in 4/8 OGBP patients, 3/8 SRG patients and 4/11 LBpatients.
Quality of life: The evaluation at 1,2,3, and 4 years showed a75 to 95 % degree of sastisfaction with the operation and theoutcome, regardless the type of operation; changes in life style(marriage, divorce, improvement on labor status, etc.) werecommon
Conclusion: According to this study, it seems that OGBPresults in somewhat greater weight loss than the other tech-niques, even though this is not statistically significant. It seemsthat these three techniques offer a good solution for severelyobese patient.
134. FROM OPEN TO LAPAROSCOPIC GASTRIC BYPASS.I. Díez del Val, C. Martínez Blázquez, J. D. Sardón Ramos, J. M.Vitores López, V. Sierra Esteban, J.Valencia Cortejoso.HospitalTxagorritxu, Vitoria-Gasteiz, Spain
Background: From April 1996 to April 2001 248 patients suf-fering from morbid obesity were operated on in our service.Vertical banded gastroplasty has been definitively abandoned
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due to complications like linear stapler disruption, poor resultsin superobese and sweet eaters and bad quality of life. We pre-sent our results with isolated gastric bypass (IGB) as primaryoperation and our current progression towards laparoscopicsurgery.
Methods: Between February 1998 and April 2001, we haveperformed 188 IGBs, 166 of them as a primary procedure(mean weight 125 kg [range, 75-214 kg] and mean BMI 47.84kg/m2 [range, 37.20-70.17 kg/m2]). Our technique consists in thecreation of a small gastric pouch of 5 x 3 cm from the lesser cur-vature to the angle of His. A biliopancreatic limb of 40 to 200 cmis performed depending on the preoperative BMI and a 70-cmalimentary limb reaches the upper abdomen via a retrocolic, ret-rogastric way. An end-to-side anastomosis calibrated to theinternal diameter of the circular stapler (12mm) completes theprocedure. At the moment, this technique has been performedby a laparoscopic approach in 22 patients with BMI <50.
Results: Hospital mortality was nil and hospital morbidityocurred in 10.2%, including 3 postoperative anastomotic leaks(1.8%) requiring laparotomy. Three patients had to be revisedsurgically due to wound dehiscence (2 cases) and an incarcer-ated umbilical hernia (reoperation rate: 6/166=3.6%). Sevenpatients (4.2%) needed blood transfusion, probably as a conse-quence of an inadequate timing in low-mollecular weightheparin administration. No splenectomies were required.Wound infections were observed in 10 cases (6%). No compli-cations but a radiological fistula occurred in the laparoscopicseries.
During the follow up, 10 marginal ulcers were observed, 9incisional hernias (22,5%=9 out of 40 cases followed-up for >2years) and four patients had to be reoperated because of symp-tomatic cholelithiasis (2), severe acid reflux and gastrogastricfistula. The mean weight was 78 kg (range, 52-130) one yearafter operation and 76 kg (45-125) at 2 years. BMI went down to30,41 kg/m2 (20.83-42.69) and 29.6 (20.72-45.31) respectively.The mean excess weight loss (EWL) was 72 and 75%. At 2years, 96% of patients (53/55) maintained at least a 50% EWL.
Conclusion: Gastric bypass is a safe, effective procedure formost morbidly obese patients, with an acceptable rate of com-plications. In selected cases, laparoscopy may offer an impor-tant reduction in abdominal wall and respiratory complications,improving postoperative comfort and recovery.
135. LAPAROSCOPIC GASTRIC BANDING FOR THE MAS-SIVELY OBESE.George A Fielding. Wesley Hospital and Royal BrisbaneHospital, Brisbane, Australia
Background: To review the experience with laparoscopic gas-tric banding for the massive obese to determine its effective-ness.
Methods: Lapbands have been placed in twenty-five patientswho had a weight over 190 kg, with an average weight of 221kg(190-335kg). Average BMI 68 (54-99). There were five womenand twenty men with an average age of forty-six years (22-63).Six patients had had previous gastric stapling which had failed.Two massively obese patients with BMI’S of 99 and 91, weigh-ing 335kg and 285kg were virtually bedridden.
Results: The bands were inserted laparoscopically. Twopatients had concurrent excision of massive abdominal pannuswith laparoscopic insertion of the band through the base of theapronectomy wound. No intra-operative, in hospital or thirty daydeaths and no deaths within three years of surgery.Weight lossresults are listed in Table.
Six bands were removed - dysphagia after previous VBG 4;erosion 1; plateau weight 1. All were removed at > 24 months.All six patients were converted to a Scopinaro bypass whichwas done laparoscopically in two (the erosion and the plateau-ing) and openly in four.There were two late deaths, both of themoccurring in patients who had the conversion to Scopinaro. Oneoccurred five years after surgery, weight having come from235kg to 105kg. At that time she had abdominoplasty and diedafter a pulmonary embolus.The second patient who had severecardiomyopathy prior to surgery, when she presented with aweight of 225 kg, died six months after Scopinaro bypass fromextension and deterioration of her cardiomyopathy.
Conclusion: Laparoscopic gastric banding with theBioEnterics Lapband is a very effective tool in the managementof the super obese. It can be inserted safely with minimal mor-bidity and results in very satisfactory weight loss which is main-tained. Laparoscopic gastric banding is a very valuable tool inthe care of the super obese.
136. HOW CAN A NEW TECHNIQUE FOR LAPAROSCOPICPLACEMENT OF THE ADJUSTABLE GASTRIC BAND (LAP-BAND) PREVENT SLIPPEAGE ? D. Wagner, R. Weiner,* U. Winterberg, H. Bockhorn.Chirurgische Klinik Krankenhaus Nordwest Frankfurt am Mainund Chirurgische Klinik Krankenhaus Sachsenhausen Frankfurtam Main*, Germany
Background: Slippage (SP) of the stomach is the most com-mon postoperative complication after laparoscopic adjustablesilicone gastric banding(LASGB) for morbid obesity.
Methods: A randomized prospective study was constructed inorder to determine whether laparoscopic placement behind car-dia (RKP) is associated with lower incidence of postoperative(SP) and pouch dilatation than after a retrogastric placement(RGP) of the LAP band using a common technique.Morbidlyobese patients presenting for LASGB were randomized toundergo either an RKP (n=50) or an RGP (n=51).
Results: There were three postoperative SP and three pouchdilations in the RGP group versus no postoperative complicationin the RKP group.
Conclusions: The placement of LAP band by the RKP tech-nique is safe and followed by a lower frequency of postoperativecomlications than with the RGP technique. Clear anatomicallandmarks are a benefit to the education and learning curve ofLASGB.
137. INFLUENCE OF GASTRIC PERFORATION, SIMULTA-NEOUS CHOLECYSTECTOMY AND WOUND INFECTION ONLATE POSTOPERATIVE COMPLICATIONS.Christine Stroh, Haralad Schramm, Ulrich Hohmann. Wald-Klinikum Gera gGmbH i.G. Departement für Allgemeine,Viscerale und Kinderchirurgie, Gera, Germany
Background: Since the introduction of gastric banding in 1983it has been a proven method in the treatment of morbid obesity,to reduce weight and maintain weight loss. We report about ourexperiences especially with a view of intra- and postoperativecomplications in connection with intraoperative complication likegastric perforation, simultan cholecystectomy and wound infec-tion and late postoperative complications like band migration
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and infection of the port system.Methods: After the introduction of the technique in 1995
about 150 were operated from February 1995 to June 1997 39patients were operated in the open technique.To years later westarted the operation of Gastric Banding laparoscopically.In thepostoperative period occurred about 15% of complications.Theconnection between complications and its cause like simultanoperations, intra- and early postoperative complications shouldbe analysed.
Results: The weight loss occurs after 6 months 34.4% and 12month after gastric banding 46.9%. In about 15 5 of the patientsa re-operation was necessary.The main indications for re-oper-ations were slippage, pouchdilatation, disconnection of theband system and complications of the port system. Rare com-plications were a stomach wall necrosis, a band migration andport infections. The influence of intraoperative complications,simultane operations and postoperative complications likewound infections to this complications should be detected.
Conclusions: A lot of complications especially after LASGBcan be prevent if there is a strong indication and an exactly stan-dardised laparoscopic technique is used without gastric perfo-ration and wound infection. Conversions to the open techniquewere sometimes necessary during the learning curve ofLASGB.
138. IS A ROUTINE GASTROGRAFIN® SWALLOW FOLLOW-ING LAPAROSCOPIC GASTRIC BANDING MANDATORY?H. Nehoda, MD; K Hourmont, MD; R Mittermair, MD; M.Lanthaler, T Sauper, MD; R. Peer*, MD; F Aigner, MD; H Weiss,MD. Department of General Surgery/ Department of Radiology*University Hospital of Innsbruck/ Anichstrasse 35/ 6020Innsbruck/ Austria
Background: To assess the value of gastrografin swallow(GS) as a method to detect postoperative complications afteradjustable laparoscopic gastric banding (ALGB) for the treat-ment of morbid obesity.
Methods: From January 1996 to January 2001, 350 morbidlyobese patients (295 women, 55 men) underwent a laparoscopicgastric banding operation. All data were prospectively collectedin a computerized databank. All patients underwent a gastro-grafin study in the early postoperative phase to exclude perfo-ration of the esophagus or stomach, which is one of the mostserious complications occurring after the gastric banding oper-ation. Furthermore, the GS was performed to confirm bandposition and to exclude early pouch dilatation.
Results: Out of the 350 ALGB operations, 6 (1.8%) earlypouch dilatations and 4 (1.2%) stomach perforations occurred.All early pouch dilatations were recognized on postoperative GSand immediately repaired laparoscopically. Of the perforations,one was recognized intraoperatively, and the other three werediagnosed postoperatively either by contrast media extravasa-tion on the GS (two patients) or by computer tomography.
Conclusion: Presently, all patients undergo routine postoper-ative gastrografin swallow, which exposes them to radiation,causes patient discomfort, and entails additional costs ofapproximately 100US$ per patient. Of the last 250 patients inour series, there have not been any cases of early pouch dilata-tion and since 1998 only one case of perforation has occurred,which could be easily clinically suspected.Therefore, we believethat in experienced centers it is not necessary to perform rou-tine postoperative contrast media studies and recommend GSonly in cases of complicated postoperative courses.
139. MOTILITY DISORDERS OF THE ESOPHAGUS FOL-LOWING ADJUSTABLE GASTRIC BANDING OPERATIONS.F. Schmoeller, G.Boehm*, K. Krichbaumer, M.Sengstbratl,R.Fuegger, F. Miess*. Elisabethinen Hospital Linz, Austria,Department for Surgery, Department for Radiology*
Background: Pouch dilatation, band dislocation and bandmigration are well known complications of ASGB-operations.The very high position of the band close to the esophagogastricjunction ( pars flaccida technique) has been suggested to pre-vent these problems. However, using the „pars flaccida tech-nique“ there seems to be an important influence on esophagealmotility in the long term. In order to evaluate the incidence ofmotility disorders we performed a retrospective analysisis of allour patients with ASGBs.
Methods: Between XII-1996 and III-2001 we implanted 237ASGBs in pts. with morbid obesity laparoscopically.As we hadused the “perigastric” technique in the first 70 cases with a dis-appointing high rate of band dislocation and pouch dilatation weoperated the following 167 pts. using the „pars flaccida“ tech-nique. All pts. underwent fluoroscopic contrast swallowing stud-ies during the band adjustment procedures. In case of clinicalsymptoms ( dysphagia, obstruction symptoms , frequent vomit-ing, inadeqate weight loss ) or pathological findings in the fluo-roscopic swollowing study we peformed a videofluoroscopicswallowing study (VFSS).
Results: In 40pts.(16.9%) we carried out VFSSs. In6pts.(2.5%) we found an extreme transport delay of more morethan 30 seconds and in another 15pts.(6.3%) we found hypo-motility of the esophagus ,10 of these pts. (4.2%) withesophageal dilatation. In 2 pts. band removal was suggesteddue to severe hypomotility and dilatation of the esophagus.In allother patients conservative treatment with unfilling of the bandand diet was successful so far.
Conclusions: Motility disorders of the esophagus have to beconsidered as serious long term complications of ASGBs andmight become more frequent indications for band removal in thefuture.
140. CONTROL AND REGRESSION OF TYPE II DIABETESAFTER BARIATRIC SURGERY.G. Vargas*, H. Cardoso*, M. Monteiro**, A. Sergio**, F. Pichel*,M. J. Pereira I Santos***, C. Cunha***, F. Bravo***. Carvalho-Santos***, H. Ramos*. Department of Endocrinology, Diabetesand Metabolism*; Surgery2** and Clinical Chemistry***, SanAntonio General Hospital, Porto, Portugal
Background: Obesity, in particular visceral obesity is, besidesgenetic predisposition, the strongest risk factor for the develop-ment of Type II diabetes. Sustained moderate weight loss canimprove glycaemic control. Bariatric surgery can be a solutionfor severe forms of obesity principally if associated to complica-tions such as diabetes.
Aim: to analyse the effects of weight loss after bariatricsurgery in a group of severally obese and diabetic patients.
Methods: We analysed 10 super-obese diabetic patients (9women and 1 man) of medium age 45,6 years old (36-56), sub-mitted to gastroplasty between 1997 and 2001, with an averagefollow up of 18 mouths (3-36). We analysed the evolution of thefollowing parameters: weight, BMI, fasting glycaemia, insuline-mia, Peptide C and HbA1c; we also analysed lipid profile andblood pressure.
Results: the diagnosis of diabetes was stablished by fastingglycaemia in 8 patients and by OGTT in the other 2. Six patientswere receiving metformin, 1 metformin and sulphonylurea and 4
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only diet. After surgery there were significant improvements inevery parameters that we analysed. After an average follow upof 18 mouths there was a weight reduction from 138.3 ± 20 Kgto 99 ± 14 Kg (p<0.0001);BMI decreased from 52.8 ± 8.5 Kg/m2
to 38,2 ± 6,6 Kg/m2 (p<0,0001), fasting glycaemia reduced from185 ± 64 mg% to 98 ± 20 mg% (p=0,002), insulinemiadecreased from 25 ± 6.7 mU/ml to 16 ± 7.3 mU/ml (ns), PeptideC decreased from 5.1 ± 1.7 ng/ml to 3.3 ± 0.7 ng/ml (ns) andHbA1C improved from 8.4 ± 1.9% to 5.4 ± 0.7% (p=0.008).Seven patients are now normoglicaemic without antidiabeticagents and the other 3 are still receiving metformin but gli-caemic control substantially changed ( fasting glycaemia nor-malized and HbA1c decreased to 6.8; 6.2; and 5.8%).Important improvements were also obtained in other compo-nents of metabolic syndrome that we analysed.
Conclusion: Bariatric surgery is an effective therapy for pro-ducing weight loss, leading to improvement and even normal-ization of glycaemic control and of other disorders of metabolicsyndrome such as dyslipoproteinemia and hypertension. Thiswould be expected to improve the long-term outcome forpatients.
141. BEHAVIOR OF INSULIN RESISTANCE AND LEPTINLEVELS AFTER BARIATRIC SURGERY.Bruno Geloneze, José Carlos Pareja, Enrico Repetto, RobertoTeixeira, Silka Geloneze, Marcos Tambascia. UNICAMP, StateUniversity of Campinas, Brazil
Background and aims: In obese subjects the circulating lev-els of leptin are elevated because the production and release ofleptin are directly related to adiposity. Weight reduction is fol-lowed by a reduction in leptin levels. The relationship betweenleptin and insulin resistance in obesity as well as their changesafter massive weight loss are still controversial.The aim of thisstudy is to assess the association of leptin and insulin resis-tance in severe obesity patients after massive weight loss.
Methods: Longitudinal clinical interventional study in 36severe obese patients underwent bariatric surgery (vertical gas-troplasty-Roux-en-Y gastric bypass) within one year follow-up.At baseline, 2, 4, 6 and 12 months after surgery serum leptinwas measured and insulin resistance estimated by insulin toler-ance test (Kitt).
Results: BMI decreased from 56.2 ± 9.4 to 35.6 ± 6.7 kg/m?.Leptin decreased and Kitt increased significant and linearlywithin follow-up (p<0.001), 78.8 ± 30.0 to 17.9 ± 11.5 ng/mL and2.5 ± 1.2 to 5.1 ± 1.7 %/min, respectivally. There were a signifi-cantly and positive correlation between leptin and Kitt during fol-low-up (r= 0.64, p<0.001). Further adjustment to BMI caused adecrease in the strength of this association. Finally we foundthat reduction in leptin was highly correlated to BMI than toinsulin resistance.
Conclusions: Leptin levels may be reduced after massiveweight loss in severely obese patients undergoing bariatricsurgery independently of the reduction in insulin resistance.
142. IMPROVEMENT OF OBESITY-ASSOCIATED CO-MOR-BIDITY AFTER BARIATRIC SURGERY FOLLOW-UP OF 18PATIENTS DURING 24 MONTHS.Cardoso H., Monteiro M., Vargas G., S?rgio A., Pichel F.,Pereira I.A, Santos M.J., Cunha C., Bravo F., Carvalho-Santos,Ramos H. Depts of Endocrinology, Diabetes and Metabolism,Surgery 2 and Clinical Chemistry, San Antonio GeneralHospital Port, Portugal
Background: Obesity is associated with increased risk of
developing diabetes mellitus, arterial hypertension, dyslipi-demia, obstructive sleep apnoea syndrome, degenerativechanges in articulations with chronic pain, peripheral venousinsufficiency leading to oedemas of the legs and reproductivechanges such as hypogonadism in males and hyperandro-genism in females. Many of these alterations can be improvedor even regressed by sustained weight loss.
Material and Methods: Eighteen patients, 16 females and 2males, submitted to bariatric surgery where evaluated during 24months. Their average weight was 130 ± 25.9 kg (91-194), witha BMI of 50 ± 9.3 (36.5-76). Among the group there was 6% ofdiabetics, 29% of hipertense people, and 39% with obstructivesleep apnoea syndrome, 59% had peripheral oedemas, 47%had arthralgia and 36% had urinary incontinence. Six of the 16women had policystic ovary syndrome and the 2 men hadhipogonadism. All were submitted to bariatric surgery for thetreatment of their obesity.
Results: Twenty-four months after surgery the average weightwas 82.8 ± 15.4 (55-110), with a BMI of 32 ± 5.8 (24-41).Among the group none has diabetes, arthralgias or peripheraloedemas. Only 12% has hypertension but easily controlled withanti-hypertensive treatment. 6% still have sleep apnoea syn-drome and these patients are those who had the most severeforms pre-operatively. Urinary incontinence affects 6 % of thefemale patients, and none presents policystic ovary syndrome.One of the two males has normalized his testosterone levels.
Conclusions: Bariatric surgery is a means of treating effec-tively not only the obesity but also the endocrine and metaboliccomplications of the disease.
143. REDUCING RISKS IN BARIATRIC SURGERY: IS SIBU-TRAMINE USEFUL?Enrico Repetto, Bruno Geloneze, José Carlos Pareja, RobertoTeixeira, Marcos Tambascia. UNICAMP-State University ofCampinas, SP, Brazil
Backgrounds and aims: Superobesity is a clinical therapeuticchallenge, but bariatric surgery has been considered a conve-nient approach. Superobesity can cause metabolic abnormali-ties and increase operatory risks. There is a small experienceusing sibutramine in those patients. The aim of this study is toevaluate the efficacy and the adverse effects of sibutramine insuperobese patients before undergoinf bariatric surgery.
Methods: 15 mg of sibutramine daily was given to 20 super-obese subjects 3 months before surgery. Antropometric mea-sures, abdominal circumference (AC), blood pressure (BP),heart rate (HR) and complains were evaluated at baseline andduring 3 months.
Results: The use of sibutramine induced a weight loss around7% after three months treatment. It was well tolerate and no sig-nificant adverse reactions occured baseline 1 month 2 months3 months weight (kg) 153.7 ± 23.6 147.9 ± 23.5 146.0 ± 23.7143.1 ± 23.5 BMI (kg/m2) 57.5 ± 6.2 55.3 ± 6.3 54.6 ± 6.2 53.6± 6.3 AC ( cm) 146.1 ± 14.8 138.2 ± 14.4 systolic BP 144 ± 11142 ± 12 140 ± 13 139 ± 12 dyastolic BP 98 ± 9 97 ± 9 97 ± 998 ± 8 HR (bpm) 81 ± 10 82 ± 8 83 ± 8 81 ± 7.
Conclusions: Sibutramine using before bariatric surgery is aself and well tolerated treatment wich may reduce weight andoperatory risks. Long term utilisation of sibutramine and itsmetabolic changes in superobese patients is something wichremains to be clarified.
144. INSULIN RESISTANCE IN THE SEVERELY OBESE ANDLINKS WITH METABOLIC CO-MORBIDITIES.
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Richard S. Stubbs, Kusal Wickremesekera. WakefieldGastroenterology Centre, Wellington, NZ
Background: The association between insulin resistance (IR)and obesity and its causal relationship with Type 2 diabetes iswell recognised.The possibility of an association, causal or oth-erwise, with other obesity related co-morbidities warrants con-sideration.
Methods: Insulin resistance was calculated pre-operatively in80 patients undergoing gastric bypass surgery for severe obe-sity (median BMI 44.5) using the Homeostasis model assess-ment method and again on at least one occasion post-opera-tively within 12 months in 59 patients. Correlations with pre-existing co-morbidities, including diabetes, hypertension, dyslip-idaemia, and hepatic steatosis and improvements in these fol-lowing surgery were made.
Results: 78/80 patients studied had insulin resistance pre-operatively which did not correlate with pre-operative weight orBMI. As expected there were positive correlations between IRand abnormal glucose tolerance and diabetes. A positive corre-lation was also found between IR and hepatic steatosis but nocorrelation was noted between IR and hypertension or levels ofcholesterol, triglycerides or Chol/HDL ratios although improve-ment in these did accompany improvement in IR after surgery.Improvement in IR was uniformly seen after gastric bypass andsooner than would be accounted for by weight loss alone.Degree of pre-operative IR was not a predictor of weight loss inthis group of patients.
Conclusions: While insulin resistance is an almost universalaccompaniment of severe obesity it is not closely correlatedwith the level of obesity. A number of important co-morbiditiesshow a clear association with IR and improvement in these aftergastric bypass may well be related to striking and rapid changesin IR.
145. EFFECT OF EXCESSIVE WEIGHT LOSS ON IMMUNE-REGULATORY MECHANISMS IN MORBIDLY OBESEPATIENTS.H. Weiss, H. Schwelberger, J. Klocker, B. Labeck, H. Nehoda, F.Aigner, G. Weiss. Departments of General Surgery and InternalMedicine, University Hospital Innsbruck
Background: The pathophysiological mechanisms that under-lie the correlation between obesity and cardiovascular diseaseare currently under investigation. An enhanced secretion oftumor necrosis factor-alpha (TNFa) and elevated levels of IL-6and C-reactive protein were discussed to trigger endothelialdysfunction and activation of immune-regulatory mechanisms inobese subjects. This study was performed assessing immune-activating factors in morbidly obese patients prior to and afterexcessive weight loss by means of adjustable gastric banding.
Patients and Methods: 40 morbidly obese patients (34female, 6 male; mean BMI 44.7 kg/m2; mean age 37 years)underwent laparoscopic adjustable gastric banding (SAGB®,Obtech; 06/1998-09/1999). Immune-regulatory factors andadhesion molecules (neopterin, sTNFrecII, TNFa, ICAM-1,VCAM-1, OLAB) were determined according to standardizedprocedures pre- and postoperatively. Eight healthy, non-obesevolunteers (mean age 33 years; mean BMI 22.6 kg/m2) servedas control.
Results: Preoperatively serum levels of TNFa, sTNFrecII, andICAM-1 were significantly increased in morbidly obese patientscompared to control subjects (p<0.01). However, levels ofneopterin, VCAM-1 and OLAB, parameters of immune-regula-tion and oxidative stress, did not reach significance between
obese and non-obese subjects. After a postoperative period ofmedian 282 days the BMI dropped significantly to 33.9 kg/m2
(mean weight loss 32.9 kg). TNFa and ICAM levels wererestored (p<0.05 versus preoperative), VCAM levels decreasedsignificantly (p<0.01) whereas neopterin and OLAB levelsremained unchanged.
Conclusion: Morbid obesity is associated with impaired levelsof immune-regulatory factors. Excessive weight reduction leadsto normalization of these factors and thereby may improveimmune-function and endothelial dysfunction.
146.NORMAL ENOXAPARIN DOSES GIVE TOO LOWPLASMA VALUES IN MORBID OBESITY.S. G. Frederiksen, L. Norgren, J. L. Hedenbro. Department ofSurgery, Lund University Hospital, Lund, Sweden
Background: Obesity is a risk factor for perioperative throm-boembolism. The risk of fatal pulmonary embolism in bariatricsurgery is estimated to be one in 2-300 patients. This is inaccordance with our experience of three pulmonary emboli insome 1.100 operations. This is despite compression stockings,early ambulation and prophylaxis with 40 mg enoxaparin(Klexane®) once daily. Specific studies on the prophylactic effi-ciency in the obese are lacking.
Methods: Nineteen patients scheduled for elective surgery(large bowel resection or obesity surgery) and BMI ranging from19 to 54 (kg/m2) were given 40 mg enoxaparin subcutaneously8 p.m. the night before surgery. Plasma samples were drawn atbaseline and hourly for the first six hours; thereafter bihourlyuntil at least ten hours post injection. Anti-factor Xa was deter-mined in plasma.For the individual curves thus generated, peakplasma concentration and area under curve was calculated.
Results: Obese patients had a significantly lower peak inplasma concentration of anti-factor Xa. Area under curve (AUC) strongly correlated to BMI.
Conclusion: The recommended dosage of enoxaparin forhigh risk patients gives plasma concentrations that cannot beexpected to give the desired prophylactic effect in the morbidlyobese. Controlled trials should be made with higher dosage,and the effect on anti-factor Xa monitored.
147. SAFETY OF BILATERAL VAGUS NERVE STIMULATIONFOR OBESITY.MS Roslin, M.Kurian, M Genovesi and F. Moody. Lenox HillHospital, New York, NY, University of Texas at Houston,Houston, TX, USA
Background: Results in canines have shown that chronicbilateral vagus nerve stimulation (VNS™) may be a safe andeffective treatment for morbid obesity. The purpose of this pilotprogram was to determine the safety of bilateral VNS in mor-bidly obese patients.
Materials and Methods: From July 2001 to December 2001,six morbidly obese patients, mean BMI = 54.11 (range 40.71 to71.11), mean age = 37.7 years (range 25 to 49) underwentimplantation of bilateral NeuroCybernetic Prosthesis (NCP®)Systems (Cyberonics Inc; Houston, Texas) to the left and rightvagus nerve trunks in the supradiaphragmatic position. NCPSystems were activated 14 to 17 days after implantation.Current was progressively increased from .25 to 4.5 mA at a fre-quency of 20 Hz and a pulse width of 500 µsec. Baseline bloodtests, EKG, Holter monitor, and upper GI series were obtainedand repeated at 12 and 26 weeks after implantation.
Results: No adverse events required discontinuation of VNS.There were no occurrences of vasovagal symptoms, EKG
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change, pulmonary dysfunction, or gastrointestinal disturbance.In one patient, output current was decreased secondary to painat higher currents. One wound infection was noted at the site ofNCP implantation. This same patient had VNS discontinuedafter 6 months because she became pregnant.
Conclusions: This pilot study indicates that chronic bilateralstimulation is safe and well tolerated in morbidly obese adults.Longer follow-up and additional subjects are necessary todetermine efficacy, optimal stimulation parameters, and idealimplantation technique.
148. SURGICAL TREATMENT OF OBESITY BY GASTRICBANDINGJean-Jacques Sala. Clinique Clément Drevon, Dijon, France
Background: description of current methods with an analysisand review. Presentation of the complications of gastroplasties.
Methods and Results: Early or late infections: these infectionsare usually due to errors in asepsis during radiological follow upinvestigations. The complications are reduced if the peopleinvolved are aware of asepsis problems related to manipulatingthe implant.Complications associated with the band may be categorised asfollows:- accidental opening of the band (<1%)- intra-gastric shift of the band.This may often be treated endo-scopically with subsequent repositioning of the band- slippage of the band
Upward slippage: slippage may occur upwards (to theoesophageal position) and cause dysphagia. Revision surgeryis required for this slippage or incorrect position.Downward slip-page (5 to 10% of cases): this is still the most common compli-cation and causes gastric dilatation above the band. It is char-acterised by pain associated with eating.A radiological follow upinvestigation is required if such pain develops.
Solutions: deflating the band and then re-inflating it a fewweeks later; if pain persists, re-operation is required to removeor reposition the band depending on the gastric problems.This is a genuine emergency as overly late intervention mayresult in gastric resection because of perforation of the free peri-toneum.
Conclusion: an analysis of current statistics does not demon-strate any difference in morbidity between gastroplasty per-formed by laparotomy or laparoscopy. There is, however, anindisputable advantage associated with coelioscopic approach,which is less incapacitating and makes the process easilyreversible.
149. HELIOGAST VS LAPBAND GASTROPLASTY.Jacques Himpens, Guido Leman. St Blasius Hospital,Dendermonde, Belgium
Background: A new device was recently introduced foradjustable silicone gastric banding (ASGB). This study was per-formed to evaluate the value of this device in comparison to awell documented and widely applied device.
Methods: Our gastroplasty population consists of two groups:the locals and the foreigners. In an effort to evaluate the newdevice all foreign patients were assigned to the well describeddevice (Lapband°, Bioenterics, Carpenteria, USA), group 1. AllBelgian patients received the new device (Heliogast°), group 2.The operative technique was the same: pars flaccida approach,burial of the band by several serosal stitches and fixation of theband by a stitch from stomach to the eye of the band (group 1)and to one of the plastic lips (group 2). The patients were seen
every 2 weeks at the clinic until stable weight loss wasachieved.The preoperative and postoperative complications, the numberof fill up visits and the weight loss were recorded.
Results: Between October 1, 2000 and March 1, 2001 130patients were treated. 64 patients received the Heliogast bandand 66 received the Lapband. Both groups were comparable insex, age and weight distribution. There were no peroperativecomplications in either group. There were two immediate post-operative complications in group 1 (acute obstruction by fundusslippage through the band) vs no complications in group 2. Twopatients in group 1 needed revision for port-tubing disconnec-tion vs zero in group 2. The Lapband patients needed three fillups (1-6) vs five for the Heliogast (2-9). Puncture of the cham-ber was achieved by palpation in 50% of the cases with theLapband and in 80% of the cases with the Heliogast. Weightloss per week was identical after three months in both groups(1.3 kg). One patient in group 2 did not lose weight, probablybecause of too large a size of the band.
Conclusion: The reoperation rate of the Heliogast was signif-icantly lower with the Heliogast band. The Heliogast band ismore difficult to puncture and needs more adjustments. Theweight loss is identical in both groups.
150.WEIGHT LOSS RESULTS OF VERTICAL BANDED GAS-TROPLASTY IN SUPEROBESE PATIENTS.Yury I. Yashkov, Tatiana A. Oppel, Oleg G. Skipenko. RussianResearch Center of Surgery, Moscow, Russia
Background: Definite number of patients undergoing VerticalBanded Gastroplasty (VBG) lost inadequate weight to leave«morbidly obese» cohort. The aim of this study is to evaluatewhether predomination of superobese (SO) patients (BMI > 50kg/m2) influences the results of VBG.
Methods: Among 67 patients undergoing Mason’s VBG since1992 in our institution 38 (56,7 %) were SO (mean parametersare presented in the table1).We compared weight loss parame-ters between morbidly obese and SO patients at 1; 1,5; 2; 3; 4;5 and more than 5 years after VBG.
Age Male BMI Body Height Excesspts. (kg/m2) mass (cm) weight(%) (kg) (kg)
Results: In spite of more absolute (in kg) weight loss in theSO patients % EWL did not differ significantly until the 3-rd year.At 3-rd year and after 5-th year after VBG % EWL was less inthe SO cohort. No less than 40 % of SO patients in the each fol-low-up periods had BMI > 40 kg/m2, i.e remained morbidlyobese. BMI in the SO group was higher in the each follow-upperiod. SO patients predominated among 20 % of patients whohad indications for revisional operations due to poor weight lossafter VBG.
Conclusion: Results of VBG in terms of weight loss dependon worse results of SO cohort. Significant part of SO patientsremain to be morbidly obese or even SO in spite of moreabsolute weight loss. Since SO patients prevail among ourbariatric patients we began performing vertical gastric bypass toachieve better weight loss results.
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151.VERTICAL BANDED GASTROPLASTY. A 12-YEAREXPERIENCE.A. l. Papakonstantinou, P. Alfaras, V. Komessidou, J. Terzis, P.Moustafelos, S. Gourgiotis, T. Anastasiou, E. Niakas, E.Mamplekou, E. Hadjiyannakis. 1st Surgical Department andTransplantation Unit of the Gen.Hospital of Athens “EVANGE-LISMOS”. Athens, Greece.
Aim of this study is to present and discuss the results and thecomplications of performing the Vertical Banded Gastroplasty(VBG) for the treatment of morbid obesity in a 12-years followup and propose some improvements on this technique for bet-ter results.
Methods: In this study 290 morbidly obese patients (226female, 64 male) were participated that met two requirements:All the patients were regular to their follow up and had com-pleted at least a postoperative period of two years.
Results: At the end of the first postoperative year 36.8% ofmales and 34.6% of females have reached normal weight (BMI22-24) while 49.7% of females and 52.6% of males were neartheir normal BMI. At the end of the second postoperative yearour results improved:64.3% of females and 75.4% of males hadreached their normal weight, while 26.6% of females and 19.2%of males were near that goal. At the end of the third postopera-tive year appeared the first recurrences. Twelve years afterapplication of this method the condition of our study group hasas follows: 46.2% of females and 57.9% of males have reachedand remain their normal weight. 15.8% of females and 17.5% ofmales are near that. In 29.6% of females and 19.2% of males ofthis study group recurrence of their obesity was observed.Complications during this period were encountered as follows:pulmonary embolism in 6 patients (2.06%), pneumonia in 3(1.03%), narrowing of the communicating lumen of the two partsof the stomach in five patients (1.7%), dehiscence of the verti-cal stomach staple line in 38 patients (13.10%), cholelithiasis in18 patients, gastric perforation in four patients, postoperative fis-tulas in four patients, significant gastritis and esophagitis in 32,intestinal obstruction in five patients, hernia in 34 and frequentprolonged vomiting in 23 patients.
Conclusion: The strictest choice of the patients who weresubmitted on this operation, the frequent and better psycholog-ical support and the more careful feeding of these patients dur-ing the early postoperative period and the reinforcement of thevertical suture of the stomach with another staple line are someimprovements of the method for better results.
152. VERTICAL BANDED GASTROPLASTY WITH SILICONERING: THE FIRST EXPERIENCE IN ROMANIA FOR THESURGICAL TREATMENT OF SEVERE OBESITY.Romeo Florin Galea, A. Ciule, D.Mircioiu, Dana Pintea, FlorinelaGalea. The Second Surgical Clinic, UMF, Cluj-Napoca,Romania
Background: The authors present the first 16 morbid obesitycases operated on in Romania through vertical banded gastro-plasty with silicon during 1997-2000.
Methods: We used the TA 90 BNTM stapler with TA 90B tita-nium cartridge following the Eckhout procedure.The pouch vol-ume could not be always mesasured exactly. We always achivedthe vertical direction from the Hiss angle.The gastric pouch cal-ibration was made with silicon ring 5-5, 2 cm. There were 9women and 7 men of ages between 38-15 years. The averageinitial weight was 142,6 kg (95-167kg). The initial BMI averagewas 50.9 kg/m2 (43.7-63.7 kg/m2).
Results: 11 patients were followed up in periods between 1and 3 years. The average weight obtained after the operationwas 82.3 (56-115 kg). The average weight loss after one yearwas 52.6kg ( 31-78kg) and the BMI average was reduced to32.5kg/m2 (25.3-45.2kg/m2). In one case the ring was removedafter 2 weeks. Vomiting was reduced after 1-2 months. In onecase there was a haematom in the wound, 2 cases had infec-tion and 2 cases eventration. There was no mortality. After ayear abdominoplasty was performed in 6 cases, underinginaland hip lipectomy in 3 cases.
Conclusion: The procedure is simple to be carried out. Theresults are excellent regarding weight loss. We had minor post-operative complications in 16 cases in comparison with compli-cations mentioned by other authors: gastric haemorrhage,gas-tric stenosis, dehiscence, underphrenic abcess.
153. MODIFIED VBG FOR MORBID OBESITY – AN EARLYINDIAN EXPERIENCE.Shrihari Dhorepatil, MD. Jahangir Hospital & Reaserch Center,Pune,India.
Background: There is a increased prevalence of obesity inIndia showed by NFI ,New Delhi report.This increase is pre-dominently seen in Indian Urban high income group popula-tion.The obesity surgery is recently introduced in last two yearsto treat morbid obesity in India.The procedure performed isVertical Banded Gastroplasty.
Methods: Between Jan-1999 to April 2001, 36 patients ofmorbid obesity with BMI 35 kg/m2-72 kg/m2 , Mean BMI 42.5kg./m2 were operated. (Weight range from 92 kgs.220 kgs.Mean Weight 120 kg).Modified Vertical Banded Gastroplastywas performed in all patients using TA 90 (Autosuture) Stapler
Results: No major complications, All patients had uneventfulpost-operative period with minor complications & all of themhave started loosing weight from the 1st. post operativeweek.The weight loss was maximum in first 6 months but con-tinued for one & half year.The average weight loss at the end ofone year was 70% of Extra Weight.Patients are satisfied withtheir small meals & changed dietary habit.
Conclusion: The morbid obesity is seen more in Indian Urbanhigh income group population.MVBG is a relatively simple &safe procedure with minimal side effects & low early morbidity &is effective in reducing weight with no early major complications& with high early patient compliance in Indian population.
154. TEN YEARS OF EXPERIENCE ON VBG IN OPENSURGERY.Stefano Cariani, D. Nottola, G. Vittimberga, S. Grani, A. Lucchi,F. Mancini, E. Amenta. Università di Bologna, Dipartimento diScienze Chierurgiche ed Anestesiologiche, Centro Studi di ter-apia Chirurgica dell’Obesità Patologica ,Bologna, Italia
Background: The treatment of morbid obesity with VerticalBanded Gastroplasty (VBG) resulting in the decrease of foodintake and seems to have lower risks and fewer side effects thanother procedures in patients having good compliance. Oftentechnical modifications concern: operation perfomed in opensurgery or laparoscopy, stomach transection or not, the lenghtof the vertical staple line, the length and the different kind ofmaterial of the band. Early complications as wound infection,thrombophlebitis and pulmonary embolism are well-known.Staple line disruption, pouch outlet obstruction, erosion of theband and incisional hernias are described. In this report we pre-sent the results of 711 consecutive patients who underwentVBG.
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P1. OPTIMAL TIMING OF INCISIONAL HERNIA REPAIRAND LAPAROSCOPIC GASTRIC BANDING.H. Bonatti, W. Kirchmayr, H. Nehoda, F. Aigner, P. Kronberger, H.Weiss. Dept. of General Surgery, University Hospital, Innsbruck,Austria
Background: Obesity represents one of the most importantrisk factors for perioperative complications and for recurrence ofhernias. Bariatric surgery is associated with a moderate risk forincisional hernia. This study was performed to develop strate-gies for incisional hernia repair in morbidly obese patients.
Patients and Methods: Seven out of 392 (1.8%) patients (twomen, five women: mean age of 51 years) underwent herniarepair simultaneously with (two patients) or after (five patients)laparoscopic implantation of a Swedish Adjustable Gastric Band(SAGB®). Four of these hernias preexisted from previousabdominal surgery at the time of bariatric procedure, one herniadeveloped following laparoscopic band placement after failedopen vertical banding at the median incision.
Results: Hernia repair was performed median 18.5 (range 0-51.5) months following SAGB implantation. Median BMI at thetime of SAGB implantation was 44 (range 35-53). At the time ofhernia repair median weight loss was 38 (range 0-85) kg. In twopatients hernia repair was simultaneously performed duringabdominoplastic, in one patient simultaneously with SAGBchange and in one patient a right subcostal incisional herniaand a median lower laparotomy incisional hernia were repairedsimultaneously. Repair techniques included direct defect clo-sure (5 patients) as well as sublay prolene net implantation (2patients). There were uneventful recoveries without woundinfections in all cases and no hernia recurrence after a medianfollow up of 2 (range 1-26) months. In two patients despite opti-mal weight loss hernia repair had to be performed due to recur-rent episodes of small bowel obstruction.
Conclusion: In morbidly obese patients, optimal managementand timing of incisional hernia repair should consider risk ofperioperative complications and recurrence as well as risk ofhernia-associated complications.
P2. REGRESSION OF HIPERANDROGENISM IN OBESEFEMALES SUBMITED TO BARIATRIC SURGERY.H. Cardoso, M. Monteiro, G. Vargas, F. Pichel, I. A. Pereira, A.
Sérgio, M. J. Santos, C. Cunha, F. Bravo, Carvalho-Santos, H.Ramos. San Antonio General Hospital, Porto, Portugal
Background: Obesity is known to increase the degree ofinsulin resistance and compensatory hyperinsulinism.As not alltissues are as insulin resistant as others like muscle, liver or adi-pose tissue, some like the ovary retain the capacity to respondto insulin in a manner dose-dependent.The result is the exces-sive production of androgens by the tecal cells leading to signsof hiperandrogenism, such as facial acne, hirsutism, anovula-tion, menstrual irregularities and infertility. Weight loss, byreducing the hiperinsulinism can improve the signs of androgenexcess and in some cases restore fertility.
Material and Methods: Ten super-obese women with signs ofhiperandrogenism were submitted to bariatric surgery (SwedishAdjustable Gastric Band by laparoscopy) for treatment of theirobesity. Their mean weight was 149.3 kg (91-239) and meanBMI 44.9 Kg/m2 (41-77). All presented with menstrual irregular-ities, three had hirsutism and complained of infertility. On pelvicultrasound only three had policiystic ovaries and LH/FSH> 3was found in only two of the patients.
Results: After an average time of 19.2 months (9-36) post-operation, the average weight was 100.1Kg (61-167), with aBMI of 40.9 (26-63). All, except one patient, were menstruatingregularly, and none had LH/FSH>3. The three patients whocomplained of infertility attained spontaneous pregnancy andgave birth to normoponderal new born.
Conclusions: Weight loss obtained through gastric banding(SAGB) in severe forms of obesity, led to the regression of clin-ical signs of hyperandrogenism and restored fertility.
P3. EFFECT OF MASSIVE WEIGHT LOSS IN GLUCOSETOLERANCE AND GHRELIN, A NOVEL GUT HORMONE.Victor Pilla, José Carlos Pareja, Enrico Repetto, BrunoGeloneze, Silka Geloneze, Marcos Tambascia.UNICAMP-StateUniversity of Campinas, SP, Brazil.
Background: Ghrelin, an endogenous ligand for growth hor-mone secretagoge receptor (GHS-Rs) , regulates pituitarygrowth hormone secretion. Pheriferic administration of Ghrelincaused weight gain in mice and rats. Intracerebroventricularadministration of Ghrelin generates an increase in food intakeand body weight. Observing these interesting points and the
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Posters
Materials and Methods: Since 1991 VBG was performed inopen surgery with the technique as described by Mason, but ina standardized fashion as follows.We didn’t isolate the terminalportion of the oesophagus and we devised an instrument(Amenta-Cariani) to standardise the placement of the gastricwindow (performed by using a 25 mm ILS®-Ethicon Inc.,Somerset, NJ, USA) and the pouch volume (about 30 cc).Vertical gastroplasty was performed using TA-90B® staplingdevice (Autosuture, US Surgical Inc., Norwalk, CT, USA). Thepouch outlet with 11 mm tube inside is surrounded by a Gore-tex‘ band, of 15 mm wide and 0.6 mm thick and the length wascalibrated on the thickness of the gastric wall not dissected tovessels. From january 1991 to may 2000, 711 patients wereoperated, 112 were male and 599 female, the mean age was 38years (range 16-69). The mean pre-operative B.M.I. was 46kg/m2 (range 35-78), mean EBW% was 215% (range 147-354)and 205 patients were classified as super obese (B.M.I.>50kg/m2). We have valued cost of operation, operational time,
hospital stay, weight lost, co-morbidities resolution, early andlate complications, revisional surgery. We assessed the degreeof weight loss according to the Reinhold classification. Patientfollow-up has included: radiographic study of the stomach, phys-ical evaluation and weight control at one month , six month andevery year post- operatively.
Results: Operative mortality was 0.3%. The mean operatingtime was 75 minutes and the mean length of hospital stay was6 days.The mean EBWL% was 46% at 1 year, 48% at 2 years,47% at 3 years and 42% from 4 to 8 years. Early specific com-plications were four (0.6%) and two gastric window bleedingneeded emergency operation. Late specific complications were31 (4.5%) in 28 patients: we found staple line disruption (3.4%),pouch dilatation and outlet stenosis (1.2%). Revisional surgerywas necessary in 27 patients (4.2%).
Conclusion: In our experience, we can readily confirm thatVBG performed in open surgery gives good results again and ischosen as restrictive procedure.
possible interaction of Ghrelin in human obesity and metabo-lism, we performed a study concerning Ghrelin concentrationsin severe human obesity ranging from normal glucose toleranceto diabetes before and after massive weight reduction.
Material and Methods: Longitudinal classical interventionstudy in 14 severely obese women (BMI=56.3 ± 10.2 kg/m2),classified according to glucose tolerance (8 normal- NGT group,and 6 type-2 diabetes- DM group), age: 32-55 years. Groupswere mathec by age and BMI. Insulin, leptin and Ghrelin wereevaluat3ed by commercial RIA (LinCO for insulin and leptin,Phoenix for Ghrelin) at baseline and 1 year after a vertical gas-troplasty and Roux-en Y by pass-( Capella”s procedure). Insulinresistance were assessed by Homa model.
Results: At baseline, there was a significant difference inHoma- ir betwenn groups (NGT= 14.3 ± 3.2 x DM= 20.3 ± 4.4,p<0.05), but not in insulin, leptin and Ghrelin levels. Aftersurgery, we found a massive weight reduction similar in bothgroups (final BMI= 36.2 ± 7.8 kg/m2, p<0.01). Homa-ir had amarked reduction after surgery in NGT (3.0 ± 2.1, p<0.01), aswell in DM (2.8 ± 0.8, p<0.01), being both froups with similarHoma-ir at 1 year follow up. Insulin decreased in NGT from 44± 7.7 to 14.7 ± 3.8 uU/ml (p<0.01), and in the DM group from59.4 ± 12.8 to 15.5 ± 10.7uU/ml-( p<0.01). Leptin decreased inNGT from 74.5 ± 24.9 to 20.9 ± 13.2 ng/ml (p<0.01). Ghrelin didnot show any difference between groups and did not changeafter weight reduction (NGT: 21.3 ± 6.7 to 29.4 ± 4.9 pg/ml, andDM: 27.7 ± 4.9 to 24.0 ± 2.3). Univariate regression analysis didnot show correlation between Ghrelin and other parameters.
Conclusions: Ghrelin was not affected by glucose tolerancestatus nor by weight changes in severely obese women. Despitethat, the role of this hormone in human obesity, food intake reg-ulation and weight changes remains to be clarified.
P4. RELATIONSHIP BETWEEN GHRELIN AND LEPTIN INOBESE SUBJECTS.José Carlos Pareja, Victor Pilla, Bruno Geloneze, EnricoRepetto, Silka Geloneze, Marcos Tambascia. UNICAMP- StateUniversity of Campinas SP, Brazil
Background: Ghrelin, a novel gut-brain peptide, acts in theregulation of growth hormone secretion. As it was isolated fromthe stomach both in rodents as well as in humans there are evi-dence of its participation also in energy metabolism. Ghrelingene expression was increased by fasting and decreased byleptin. Human obesity has been considered as a leptin resis-tance state as serum levels are elevated in obesity matched bybody mass index. The aim of this study is to verify the relation-ship of ghrelin and leptin in a wide variation of BMI in humansand to study the possible relationship of ghrelin-an adipogenichormone- in the pathogenesis of severe obesity.
Materials and Methods: We studied 14 severe obese patientsand 14 normal controls. Ghrelin was measured by radioim-munoassay using a commercial kit provided by Phoenix.Intraassay variation coefficient was 13.3%. Leptin was analysedusing a kit provided by Linco Co wiyh an intraassay variation of10,5%. Insulin was analysed by RIA using a kit by Linco Co.
Results: Normal controls have BMI of 24.2 ± 1.5 kg/m2, leptinlevels were 7.0 ± 3.9 ng/ml, ghrelin of 67,1 ± 11.9 pg/ml andinsulin levels were 10.5 ± 2.5 uU/ml. The severe obese patientshave BMI of 56.3 ± 10.2, leptin of 80.2 ± 30.2, ghrelin of 23.2 ±6.7 and insulin levels of 37.5 ± 18 uU/ml. Univariate regressionanalysis showed a negative correlation of ghrelin and leptin, r=-0.51 (p< 0.01).
Conclusions: We observed in this study that ghrelin, a gut-
brain peptide, is maintained blunted in severe obese patientsand correlates inversely to leptin levels. Differently that washypothesised, ghrelin is not elevated in severe obese subjectsand it is down-regulated in those subjects.These down- regula-tion may be a consequence of elevated levels of leptin and orinsulin.
P5. TYPE-2 DIABETES, GLUCOSE CONTROL ANDINSULIN RESISTANCE FOLLOWING MASSIVE WEIGHTLOSS.Bruno Geloneze, José Carlos Pareja, Enrico Repetto, SilkaGeloneze, Roberto Teixeira, Marcos Tambascia. UNICAMP-Sate University of Campinas, SP, Brazil.
Background: Bariatric surgery has been shown to be mosteffective therapeutic approach for extreme obesity.Several stud-ies have reported that surgery is able to improve the glucosecontrol. It is noteworthy that bariatric surgery allows the supres-sion or, at least, drastic reduction of antidiabetic drugs.The rela-tionship of glucose control and insulin sensitivity in thosepatients is poorly investigated.
Materials and Methods: We followed up 10 type-2 diabeticpatients undergone vertical gastroplasty with Roux-en-Y bypasswithin one year, observing their glycemic control and insulinsensitivity estimated by an insulin tolerance test (ITT) performedinitially, 6 and 12 months after surgery.
Results: A massive reduction of 70% in the initial excess bodyweight was achieved one year after surgery. The insulin sensi-tivity index (KITT) showed a significant increase during the fol-low up period (r= 0.53, p< 0.01). We observed a strong linearcorrelation between KITT and glucose levels (r= -0.50, p<0.01),and with HbA1C (r= -0.51, p<0.01).This metabolic improvementwas observed despite an impressive interruption of any phar-macological treatment of diabetes within one year follow up.Baseline 6 mo. 12 mo. BMI (kg/m2) 54.1 ± 8.7 40.6 ± 7.6 35.5 ±6.1 Glucose (mMol) 10.8 ± 4.9 5.7 ± 1.3 4.6 ± 0.5 HbA1C (%)7.6 ± 2.2 4.9 ± 0.3 4.6 ± 0.7 KITT(%min) 1.65 ± 1.02 3.76 ± 1.654.43 ± 2.34.
Conclusions: Weight loss is a major target in treatment ofobese patients with type-2 diabetes. In this group the remark-able weight reduction was effective on improving glycemic con-trol. This effect on glucose metabolism is due to a significantincrease in insulin sensitivity observed in this population.
P6. INFLAMMATORY MARKERS, INSULIN RESISTANCEAND WEIGHT LOSS FOLLOWING BARIATRIC SURGERY.Bruno Geloneze, José Carlos Pareja, Enrico Repetto, RobertoTeixeira, Silka Geloneze, Marcos Tambascia. UNICAMP–StateUniversity of Campinas, SP, Brazil
Background: Obesity has been described as a inflammatorystate. Some markers of this condition are elevated in obesitysuch as fibrynogen, coagulation factors, C-reactive protein andwhite blood cells count (WBC). The relationship between WBCand insulin resistance, as well as the effect of weight reductionin this relation are still controversial.The aim of this study is toassess the association of white blood count and insulin resis-tance in severe obesity before and after massive weight loss.
Methods: Longitudinal clinical interventional study in 46severe obese patients submitted to a bariatric surgery (verticalgastroplasty Roux-en-Y gastric bypass) within one year follow-up. At baseline, 2, 4, 6 and 12 months after surgery white bloodcounty was measured and insulin resistance estimated byHOMA.
Results: BMI decreased from 54.5 ± 8.9 to 34.5 ± 6.3 kg/m2.
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WBC acid and HOMA-IR decreased significant and linearlywithin follow-up (p<0.001), 9.2 ± 2.0 to 6.5 ± 1.7 mg/L and 16.8± 12.0 to 3.0 ± 1.4, respectivelly.There were a significantly andpositive correlation between WBC and HOMA-IR in basal state(r= 0.37, p<0.05), and during follow-up (r= 0.36, p<0.05).
Conclusions: An important determinant of the WBC in severeobese patients before and after reduction was the insulin resis-tance index. Thus WBC could be a component of insulin resis-tance state and may be reduced after massive weight loss, pos-sible indicating a reduction in inflammatory associated condi-tion.
P7. INSULIN RESISTANCE AND URICEMIA IN SEVEREOBESE SUBJECTS FOLLOWING BARIATRIC SURGERY.Bruno Geloneze, José Carlos Pareja, Enrico Repetto, SilkaGeloneze S, Marcos Tambascia. UNICAMP–State University ofCampinas, SP, Brazil
Backgrounds: Hyperuricemia is associated with componentsof metabolic syndrome as hyperlipidemia, impaired glucose tol-erance, hypertension and obesity. The relationship betweenserum uric acid and insulin resistance, as well as the effect ofweight reduction in this relation are still controversial.The aim ofthis study is to assess the association of hyperuricemia andinsulin resistance in severe obesity after massive weight loss.
Methods: Longitudinal clinical interventional study in 48severe obese patients submitted to a bariatric surgery (verticalgastroplasty Roux-en-Y gastric bypass) within one year follow-up. At baseline, 6 and 12 months after surgery serum uric acidlevel was measured and insulin resistance estimated by HOMA(HOMA-IR index).
Results: BMI decreased from 54.5 ± 8.9 to 34.5 ± 6.3 kg/m2.Uric acid and HOMA-IR decreased significant and linearlywithin follow-up (p<0.001), 6.9 ± 4.5 to 4.8 ± 1.4 mg/L and 15.4± 12.1 to 2.9 ± 1.5, respectivelly.There were a significantly andpositive correlation between uric acid and HOMA-IR in basalstate (r= 0.37, p<0.01), and during follow-up (r= 0.51, p<0.001).Further adjustment to BMI caused a decrease in the strength ofthis association, however the influence of BMI variationappeared to be weaker than HOMA-IR reduction.
Conclusions: The major determinant of the serum uric acidlevels in severe obese patients following weight reduction wasthe insulin resistance state. Thus uric acid levels may bereduced after massive weight loss due to reduction in insulinresistance.
P8. INTEGRATED SURGICAL APPROACH TO OBESITY.George A Fielding. Wesley Hospital and Royal BrisbaneHospital, Brisbane, Australia.
Background: This paper reviews result of an integrated man-agement plan for morbidly obese patients, combiding Lapbandand Laparoscopic Scopinaro Bypass, to assess the place ofboth in one practise.
Methods: Since February 1996 lapband has been used (895)for morbid obesity. In July 1998 Scopinaro Bypass was com-menced and has been done laparoscopically since August1999. Total 181 - 109 laparoscopic (76 with BPDDS and sleevegastrectomy).
Results: Lapband (895). Three converted to open-one death(perforated duodenal ulcer); hospital stay 1.8 days (1-9); weight142kg (85–365kg); BMI 47 (34–99). At three years BMI 27.Weight loss maintained at 4.5 years in first fifty cases.Complication-erosion 4; slip 62 (8 in last 415 since changing toposterior approach); dysphagia needing removal 39.
Scopinaro (181). Indications-previous obesity surgery (VBG,rigid bands) 35; dysphagia after lapband 37; eroded bands 4; bychoice 21, public hospital availability 84. Weight 148kg (72-255kg); BMI 45 (29-85); mortality 0; hospital stay-open 9 days,laparoscopic 5 days. Complications-leak 6; PE 1.
Conclusion: The ease of lapband, rapid return to normalactivity and lack of bowel complications make it the author’s firstchoice. BPDDS (laparoscopic) is a great alternative and excel-lent fallback position in the 6% who do poorly with lapband.
P9. LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING INSUPER-MORBID OBESE: AN EGYPTIAN EXPERIENCE.Hany Aly Nowara, MD, FRCS. Cairo University Hospital andMokattam Surgery Center, Egypt
Background: Gastric banding is now widely practiced formanagement of morbid obesity. Doubts have existed over itsrole in treatment of Super-morbid obese. The purpose of thisstudy is to assess the results of gastric banding in 136 patientswith BMI above 50 Kg/m2.
Methods: 136 super-morbidly obese patients having a bodymass index (BMI) >50 hg/m2 were included in this study. 56patients had a BMI above 60 Kg/m2.The procedure was per-formed through a 4 or 5 trocar technique. Pneumoperitoneumand first trocar insertion were done via the open method. Twoinsuflators were used with extralong instruments.Endoillumination of the esophagus was done in all cases
Results: The mean age of the patients was 41.3 years. Themean BMI was 59.1 Kg/m2. All procedures were completed bylaparoscopy. The mean hospital stay was 3.2 days. The meanBMI after 12 months was 44.2 kg/m2 & after 24 months was34.2 kg/m2. The mean follow-up was 26 months (6-48). Therewere no mortalities in this series .
Conclusions: laparoscopic insertion of the adjustable gastricband proved to be suitable for superobese.Gastric banding is asafe and effective method for the treatment of super morbidobesity in Egyptian patients.
P10.BARIATRIC SURGERY FOR CHILDREN AND ADOLES-CENTS: WHAT ARE THE INDICATIONS?Khaled Gawdat, MD, Ashraf Kabesh, MD. Ain Shams School ofMedicine, Cairo Egypt.
Background: Eighteen years of age is the minimum acceptedage for bariatric surgery. Some times morbid obesity affects chil-dren and adolescents who may need bariatric surgery at ayounger age. We present our results of bariatric surgery in thisage group.
Methods: 29 morbidly obese of age <18 years old received abariatric surgical procedure with a mean follow up period of 16.9months (3-42 months). The mean age was 15.9 years old (9-18years).The mean weight was 144.6 kg (97-250 kg) with a meanBMI of 53.8kg/m2 (40.1-77.2 kg/m2) and the mean EBW was85.5 kg (45.8-178.7kg).19 patients had vertical banded gastro-plasty (VBG), 3 patients had laparoscopic adjustable gastricbanding (LAGB) and 7 patients had Roux-en Y gastric bypass(RYGB). The reason for interfering at <10 years of age wassevere skeletal deformity together with super-obesity. 82.7% ofthe patients had a BMI >50 kg/m2. 31% had hypertension,17.2% had respiratory insufficiency, 3.4% had gall stones,51.7% had joint problems, 10.3% had severe skeletal deformi-ties interfering with walking, 58.6% had chronic back problems.70% of the female patients had menstrual troubles.
Results: Hospital stay was a mean of 4.86 days.Postoperative complications: No mortality, 2 patients had GIT
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leakage, 5 patients had wound infection, 1 patient had incisionalhernia. Patients lost a mean of 60.2% of their excess bodyweight 12 months after surgery. At 24 months after surgery themean excess body weight loss dropped to 54.3%.Hypertension was cured in 100% of the patients, menstrualproblems were corrected in 85% of the patients and ambulationwas improved in all of the patients.
Conclusion: Bariatric surgery can be utilized at younger agesif super obesity is present especially in the presence of skeletaldeformities. Out come of surgery in this patient group was sim-ilar to the outcome in the adult population but longer follow up isnecessary to confirm this finding.
P11.THE EVALUATION OF ETIOLOGY, RISK FACTORS ,COMPLICATIONS AND BENEFIT, USING THE DATA BASE“OBESITY 2.0” FOR LAPAROSCOPIC BARIATRICSURGERY.D. Wagner, R. Weiner,U.Winterberg, H. Bockhorn. Departmentof surgery, KH Nordwest, Frankfurt a.M., Germany
Background: The complex data of obese patients undergoingbariatric surgery had to be documented and evaluated.Therefore a system-software will be necessary.
Methods: On the base of FileMaker Pro programm a database for patients before and after laparoscopic gastric bandingwas developped.The programm works with Windows and Mac.All data, which were important to select patients for bariatricsurgery were included.
Results: The etiology, risk factors, patient history and thepostoperative follow-up of 1287 patients were documented inthe data base. The import and export of files into other pro-gramms is easy to perform. Statistical analysis can be per-formed by means of EXCEL and other programms. The data-transfer by internet is usefull.
Conclusions: The data base “Obesity 2.0” allows a complexregistry, selection and follow-up of patients undergoing bariatricsurgery. The system can be established and used very easily.
P12.LAP-BAND PERSISTING GOOD RESULT WITHSLIPPED BAND BY MODIFIED TECHNIQUE.George A Fielding. Wesley Hospital and Royal BrisbaneHospital, Brisbane, Australia
Background: Slip has been the major problem with lapbandsurgery. Eight hundred and ninety five bands have been per-formed by the author since February 1996.
Methods: In the first 480 cases performed up to December1998, prior to change in technique, there have been 54 slips(12%). These occurred at 11 months (4–52) after surgery. Allpresented with reflux, dysphagia to solids and often asthma. Allbands were repositioned.Ten went on to Scopinaro Bypass dueto persistent dysphagia. Due to this problem, the authorchanged to a posterior approach, going through the lesseromentum, behind the O-G junction, above the lesser sac.Thereis a small anterior pouch with gastro-gastric suturing over theband anteriorly.
Results: In the thirty months since December 1998 therehave been 415 bands inserted with the new technique. Therehave been 9 slips (2%). These occurred at 10 months (6-14).Two have had acute slips with ischaemia of the stomach funduscharacterised by extreme pain. One presented late and diedwith peritonitis. Three have had the band removed and conver-sion to laparoscopic BPDDS.
Conclusion: The incidence of slip is greatly reduced by theposterior approach via the lesser omentum. Patients should be
warned of the rare complication of acute gastric ischaemia dueto strangulation with the slip.
P13.THE EFFECTS OF LONG LIMB GASTRIC BYPASS ONMONOCYTE DYSFUNCTION IN MORBID OBESITY.L. D. G. Angus, MD, D. R. Cottam, MD, D. Fahmy, MD, G. W.Shaftan, MD, P. A. Schaefer, PhD. Nassau University MedicalCenter, Department of Surgery East Meadow, New York, USA
Background: There is a large body of epidemiological dataassociating obesity with various cancers and wound infections.However, information on the monocyte role in the immune func-tion of obesity has been lacking. We investigated several cellsurface antigens on monocytes and followed their response tosurgically induced weight loss.
Methods: Twenty-seven patients having gastric bypasssurgery for obesity (BMI>40) were compared to 10 normal con-trols (BMI<26). Relative monocyte frequencies and expressionof the activation antigens CD11b (integrin adhesion molecule),CD 14 (LPS receptor), CD16 (Fc receptor), CD14/CD16 subset(inflammation parameter), and CD62L (L-selectin, adhesionmolecule), were evaluated by flow cytometry. Additionally cellcounts were made.
Results: The study control group had a mean age of 37 ± 7.6(range 30 to 57) with no significant health problems.Their meanbody mass index (BMI) was 23 ± 2.5 (range 21-26). The meanage of the sample group was 40.36 ± 13.7 (range 18 to 60) witha mean BMI of 52 ± 8.2 (range 41 to 72). The relative monocytefrequencies in the obese patients were statistically similar tocontrols throughout the study period. Likewise CD11b andCD16 did not differ from controls throughout the three-monthstudy. A significant reduction of CD62L (L-selectin) expressionwas noted in the morbidly obese with respect to controls (gmf104 vs. 246, p= <0.001). There was an inverse relationshipbetween elevation of BMI and depression of L-selectin usingpearson’s correlation at baseline (p=0.037). This depressioncontinued through one month but by three month there was nota statistical difference (gmf 203 vs. 246, p=0.3).The LPS recep-tor molecule CD14 was significantly elevated in comparison tonormals (gmf 1129 vs. 658, p=0.022).This difference continuedthrough the first month post operatively. Yet, by the third monththis difference had disappeared statistically (gmf 809 vs. 658,p=0.312).The last variable studied was CD14/CD16 subset per-centages. The levels of this were statistically elevated through-out the three month study period when compared to controls,but declined with weight loss, median values preoperativelywere 14 (25%= 11.5, 75%= 16.00, p=0.004), 12.8 at one month(25%=10.75, 75%=17, p=0.007), and at three months 11.1(25%=9.4, 75%=16.6, p=0.036).
Conclusion: Discordant CD11b/ CD62 levels with elevatedCD14 and CD14/CD16 subset percentages suggest that achronic inflammatory and chronic immuno-deficient state existsin the monocytes of morbidly obese patients. Additionally, ourfinding of reduced expression of CD62 suggests a pronouncedimpairment exists in the monocytes’ability to migrate to sites ofinflammation.This dysfunction is reversible with gastric bypass.
P14.ABNORMAL VIDEOFLUOROSCOPIC FINDINGS INPATIENTS AFTER LAPAROSCOPIC GASTRIC BANDING.G. Boehm1, F. Schmoeller2, K. Kriechbaumer2, F. Miess1, R.Függer2. 1Department of Radiology, Elisabethinen HospitalLinz, Austria 2Department of Surgery, Elisabethinen HospitalLinz, Austria
Background: To evaluate the frequency of morphological and
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functional disorders of the esophagus in videofluoroscopic swal-lowing studies (VFSS) of patients with morbid obesity treatedwith laparoscopic adjustable gastric banding more than oneyear before.
Methods: We carried out 40 VFSS in patients after Gastric(11) and Esophagogastric (29) Banding who had been operatedbetween 1998 and 2000. 39 female pts. and 1 male pt. wereexaminated VFSS was performed with a standard protocol andin addition plain films were made.The clinical criteria to make aVFSS were: dysphagia, obstruction symptoms, inadequateweight loss, increase of vomiting, inadequate transport of con-trast agent in normal fluoroscopy usually done by the surgeon.According to the clinical symptoms the radiological criteriawere: position of the band, presence of a pouch, esophagealdilatation (normal £4cm), transport delay (10 ml Barium-Suspension <10 sec.) and propulsive contractions of the esoph-agus.
Results: In 40 pts. 35 morphological and dynamic findings in25 pts. (62.5%) could be depicted including:4 dislocated bands,6 pts. with an extreme transport delay (more than 30 sec.), 15pts. with a conspicuous hypomotility of the esophagus followedin 10 pts. by an esophageal dilatation.
Conclusion: Functional impairment of the esophagus seemsto be frequent in patients after LAGB. If morphological abnor-malities are absent , the diagnosis of dynamic disorders shouldbe considered. VFSS is a radiological method to reveal func-tional and morphological abnormalities in patients after laparo-scopic gastric banding as a treatment of morbid obesity.
P15.ESOPHAGO-GASTRIC LAPAROSCOPIC PLACEMENTOF LAP-BAND FOR MORBID OBESITY: CONSIDERATIONSAFTER THE FIRST 80 CASES.Sergio Boschi, L. Fogli, A. Cuppini*, M. Brulatti, P. Patrizi, V.Papa, M. Di Domenico, F. D. Capizzi. General Surgery and*Internal Medicine, Bellaria Hospital, Bologna, Italy
Laparoscopic gastric banding is an effective surgical methodfor the treatment of morbid obesity, but is fraught with specificcomplications, like slippage and gastric erosions.To reduce theincidence of such complications, several technical variants havebeen used, including high retro-gastric positioning, above thebursa omentalis, complete anterior fixation through gastro-gas-tric stitches around the lapband, reduction of the gastric pouchvolume to 15 ml or less.
These technical variants end up inducing dysphagia. Thetechnique adopted by us, consisting in placement of the pros-thesis around the esophagus, 2 cm above the gastro-esophageal junction, is aimed at inducing an amplification ofthis mechanism. No fixation of the gastric wall is needed. SinceJanuary 1999, 80 consecutive patients have been operated onlaparoscopically this way, using the 9.75 cm Bioenterics®
Lapband.Complications include two cases of slippage: an early one,
after 24 h, requiring surgical removal, and a late one, after 9months, treated by laparoscopic re-positioning. In both cases, asmall part of the gastric wall was accidentally included withinthe lapband. In another case, a reactive esophageal stenosisoccurred in a trans-sexual male patient under estrogen hor-monal treatment: substitution with a wider Swedish lapband wasneeded. No more complications have been registered. Patientcompliance has been good, and results of BMI and excessweight reduction (42% and 50%, respectively after one and twoyears) have been noteworthy.The technique here descibed hasa re-educational function, in that patients are induced to chew
up thoroughly, to introduce small morsels of food and prolongthe mastication time, to avoid dysphagia.
In conclusion, we can affirm that esophago-cardiasic bandinggives no problem if well positioned; promotes new alimentaryhabits through a dysphagic mechanism, inducing this way a sig-nificant BMI and excess weight reduction.
P16.APOLIPOPROTEIN E AND CIII IN PATIENTS WITH OBE-SITY-RELATED PHENOTYPE BMI AFTER BARIATRICSURGERY.J.C. Cagigas*, Alfredo Ingelmo*, R. Hernandez-Estefania, D.Gonzalez-Lamuño, M. Garcia-Ribes, S. Revuelta*, C. EscalanteNutrition and Cardiovascular Risk Unit. University of Cantabria;General Surgery. Hospital Universitary Valdecilla, HospitalSierrallana*, Spain.
Background: Recent research on obesity has revealed thatbody weight is in fact a truly complex phenotype.Body weight isinfluenced by any factor that influences the weight of any indi-vidual tissue, organ, or fluid. We analyses the influence amongthe obesity-related phenotype BMI after bariatric surgery andgenetics polimorphs E and CIII.
Methods: 54 patients were treated by vertical banded gastro-plasty (VBG). All patients were women with a mean age of 35.4(range 20-46) years. Mean body-weight was 128kgs. (105-146)and mean BMI was 49.58 (35.6-53), before surgery. Others 135patients were control group (N) with 110 women. Study of thegenetics polimorphs apolipoproteins:Apo E, Apo CIII were per-formed with techinques of specific digestion with restriction senzyme and PCR reactions-termociclator. Analysis statisticswere t of Student, Mann Whitney, odds ratio and statistic pro-gramm V.2
Results: The relative prevalences for the polimorphapolipoprotein E of the alelos e2, e3, e4 (group VBG) were 0.06,0.84, 0.1 respectively. No have any differences between gen-ders. Only was founded four of the total six feasible genotypesinfluenced for the tree alelos linkaged apolipoprotein E as it wasnot founded any patient e2/e2 ni e2/e4. Similar prevalences(e2=0.04; e3=0.87; e4=0.09), were in group control (N). Thegenotype E4/E3 was presented more decrease in cholesterolthan E3/E3:p=0.0024. The relative prevalences for polimorphapolipoprotein CIII with 2 alelos genotypes S1/S2 were 0.95/0.05 in the obese patients respectively. No differences in groupN (S1=0.94; S2=0.06). In relation to the asociation of unbalanceamong the presence of isomorph S2 from gen of theapolipoprotein CIII and mutations that relation to the goldsequence for the insulin in the región promoter of the same gen,was noticed that all patients with alelo S2 showed at least oneof the two mutations described –482; -455. The patients withgenetic polimorph Apo E and genotype E4/E3 showed mean ofcholesterol was 204.8 mg/dl, more elevated than genotypeE3/E3 (193 mg/dl) before surgery.
Conclusions: In our population, the polimorph S2 for apoCIIIis associated with a mutation in one region of the gen over feed-back insulin. No have any association with diabetes or glucosealteraded with genotype S1/S2. The morbid obese patients pre-sent more decrease of levels of cholesterol with the presence ofisomorph E for apoprotein E (group E4/E3, p=0.022), 6 monthsafter vertical banded gastroplasty.
P17.OBESITY SURGERY PITFALLS AND MORBIDITY AT10-YEAR FOLLOW-UP WITH VERTICAL BANDED GASTRO-PLASTY.J.C. Cagigas*, Alfredo Ingelmo*, R. Hernandez-Estefanía, F.
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Olmedo, S. Revuelta*, E. Martino, C.F. Escalante. HospitalValdecilla. Hospital Sierrallana*, University of Cantabria, Spain.
Background : Vertical banded gastroplasty (VBG) has provenitself an efficient bariatric procedure in morbidly obese patients,resulting in a dramatic body mass index (BMI) reduction duringthe first postoperative year. In the past 10 years, we have anal-ized 170 morbidly obese patients follow-up underwent thissurgery in Hospital of Valdecilla.
Methods: One hundred seventy consecutive morbidly obesepatients who underwent a VBG were followed up during 10years. BMI evolution was monitored.The mean patient age was45 years (range 18-66 ). There were 143 women and 27 menwith a mean body weight of 124 kgs. (range 100-245) who weremean BMI of 52.8.%.
Results: In the overall evolution of BMI at 10 years 87% ofpatients had a BMI over 35 put into the category of low-riskweight, a value considered an indicator of the successor failureof the intervention. In the post-operative assessment the aver-age time in hospital was 11.8 ± 5.39 days. At the 10-year follow-up visit, vomiting and constipation were reported less frequently.On the other hand, half of the patients expressed a clear ten-dency to commit dietary transgressions, and to ingest food atunscheduled times.The morbidity during the immediate postop-erative was in 5 patients: wound infection (2), adult respiratorydistress syndrome (2), and suture dehiscence associated withperitonitis (1). The morbidity at the 10-year follow-up was in 15patients (9.6%), whose were reoperated: 2 stenosis neo piloroand reconverted to Fobi, 5 weight gain with 2 reconverted toFobi (one of them is 3-ro), 2 sutures dehiscence from staple justreconverted to another re-VBG and other to Scopinaro, 6 inci-sion hernia (3 associated with 3 cholecistectomy). Fourteenpatients underwent associated cholecystectomy (2 with theVBG, 5 with the reoperations and 7 during the follow-up period).The mortality was in 3 patients due to respiratory failure andsubphrenic abscesses with sepsis and multi-organic failure.
Conclusions: We conclude that vertical banded gastroplastyat long term can reduce overweight of obese patients but notcure obesity. Pitfalls and morbidity were minor than 10%.Reoperations were performed avoid more morbidity and gainweight.
P18.SMALL BOWEL OBSTRUCTION FOLLOWING LONGLIMB ROUX EN Y GASTRIC BYPASS FOR MORBID OBE-SITY. PRESENTATION OF 3 CASES.T. Daskalakis, J. Nicastro, H. Mcmullen, G. Coppa, J. N.Cunningham, J. Macura. Maimonides Medical Center, Brooklyn,NY and Staten Island University Hospital, Staten Island, NY,USA
Surgery for morbid obesity has become one of the most suc-cessful modalities for dealing with a clear public health issue.The Roux en Y Gastric Bypass (RYGB) has become the “goldstandard” procedure in the United States over the past decade.Approximately 36,000 bariatric procedures are performed in theU.S. each year of which 25,000 are RYGB’s.
We report three cases with bowel obstruction after RYGB. Inall three patients the obstruction was near the enteroenteros-tomy site. In the first patient the obstruction was of the alimen-tary limb, while the other 2 patients had a complete obstructionof the biliary limb.The patient with obstruction of the alimentarylimb developed gangrenous ischemia of the proximal bowel.One of the patients with biliary limb obstruction developed gan-grenous perforation of the stomach and the other underwentlysis of adhesions and decompression prior to ischemic change
or perforation.Obstruction of the biliary limb of the RYGB, by definition, con-
stitutes a “closed loop”. Because of the unique anatomy of theupper gastrointestinal tract, obstruction of this limb presents adiagnostic challenge. Failure to promptly diagnose and inter-vene can lead to devastating consequences. In order to raisethe awareness of practitioners in the community to this potentialproblem we, herein, present two cases of biliary limb and onecase of alimentary limb obstruction after RYGB and review therelevant literature.
P19.THE USE OF ENDOSTAPLERS IN THE RECONVER-SION OF A FAILED VERTICAL BANDED GASTROPLASTYTO BILIOPANCREATIC DIVERSION (SCOPINARO).C. F. Escalante, A. Domínguez-Diez, A. Ingelmo, F. Olmedo, M.G. Fleitas. Institute of Digestive Diseases. Hospital U. “Marquésde Valdecilla”. Santander. Spain.
Background: The vertical banded gastroplasty has beenwidely used for the last years in morbid obesity surgery. Itsresults are controversial because patients gain or do not lossthe expected weight (2 and 5 years later). These patients use tohave a pre-gastroplasty Body Mass Index (BMI) >45 or veryspecific personal alimentary costumes. In such cases newsurgery consists of both restrictive and derivative techniques,either a gastric bypass or a biliopancreatic diversion. We pre-sent a serie of 18 patients who underwent a reconversion of aprevious gastroplasty, performing a biliopancreatic diversionusing endostaplers in all the steps of surgery. We obtainedexcellent results and no mortality, with shorten in hospitalisationand a significant reduction in morbidity.
Methods: Surgery of morbid obesity was firstly introduced inour Hospital in 1989, since then 175 vertical banded gastro-plasties have been performed. After 2 years, and more impor-tantly after 5, up to 45% of patients start to gain weight. Thesepatients use to have a pre-gastroplasty BMI >45 or specific ali-mentary habits. We made reconversions in 18 patients, whounderwent vertical banded gastroplasty and gained weight. Inall the cases a biliopancreatic diversion was performed, usingendostaplers in all the steps of surgery, sections and anasto-mosis, taking the previous band out and cutting off the staplersline of the stomach with the endostapler.At 4th or 5th day aftersurgical operation a radiological barium control was made.
Results: Results are globally good.At one year follow-up aftersurgery, a reduction of 75% of overweight has been observed,with a good quality of life assessment with several tests.Surgical time has been reduced to 135 minutes. There havebeen no deaths and morbidity is very low. No anastomotic fis-tula has developed, no biliar leakage or metabolic-respiratorycomplications have been observed. The unique complicationhas been an infection of surgical wound.
Conclusions: According to our experience, biliopancreaticdiversion performed with endostaplers is a good option for failedgastroplasties. It diminishes surgical time and postoperativecomplications.The results on weight loss and quality of life areexcellent.
P20.QUALITY OF LIFE AFTER ROUX-EN-Y GASTRICBYPASS (RYGBP).Joel Faintuch, Priscilla L.R.C. Machado, Monica A. Rudner,Arthur B. Garrido Jr , Luiz V. Berti, Marlene M. Silva, J.J. Gama-Rodrigues. Obesity Surgery Group, Hospital das Clinicas, SaoPaulo, SP, Brazil
Background: Weight loss is the main registered variable after
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bariatric procedures, but patients’ feelings and reactions in thepostoperative period are also valuable.In a prospective study of200 consecutive RYGBP subjects, BAROS quality of life testwas applied, aiming to define the psycho-social impact of theoperation.
Methods: Response to the questionnaire was divided intoMoorehead-Ardelt (MA) quality of life score (-3 to +3) and Oria-Moorehead (OM) protocol, which included the former plus nutri-tional, medical and surgical results (1 or less up to 9 points).Ageof the population was 39.6 ± 6.0 years (82.0% females), 85.5%of the group suffered from comorbidities, and follow-up periodwas 17.6 ± 8.0 months. Preoperative Body Mass Index (BMI)was 50.0 ± 8.9 kg/m2, and 64.6 ± 9.0% of excess body weightwas eliminated, to a BMI of 31.7 ± 4.6 kg/m2.
Results: MA outcome was 1.6 ± 1.0, with 5.0% failures(greatly diminished, diminished or unchanged quality), 57.0%had improved and 38.0% had greatly improved after surgicaltreatment. OM protocol revealed 5.2 ± 1.9 points, with 9.5%failed or fair results, 37.5% good, 35.0% very good, and 18.0%excellent outcomes. Preliminary matching of the two sets offindings was already imperfect, and when MA numbers wereeliminated from the complete OM questionnaire, statistical sim-ilarity was weak (p< 0.05).
Conclusions: 1) General scores for quality of life and generaloutcome of the operation (AM and OM tests) corresponded toexpectations, with a large majority of good and excellentresponses; 2) Separation of clinical course from psycho-socialimpact indicated that these results are relatively independent;3)Further studies are necessary to identify prognostic factors forpatient insatisfaction with surgical outcome despite appropriateshedding of excess body weight.
P21.RESPONSE OF COMORBIDITIES TO ROUX-EN-Y GAS-TRIC BYPASS (RYGBP).Joel Faintuch, Monica A. Rudner, Priscilla L.R.C. Machado,Arthur B. Garrido Jr, Marcelo R. Oliveira, J.J.Gama-Rodrigues.Obesity Surgery Group, Hospital das Clínicas, Sao Paulo, SP,Brazil
Background: Comorbidities contribute not only to surgicalindication, but also to a large measure of success or failure ofbariatric operations. Nevertheless, rates of response of individ-ual troubles are disputed. In a prospective study of 200 consec-utive RYGBP subjects, 16 diseases or manifestations were fol-lowed, aiming to document their relief or not after surgical treat-ment.
Methods: Variables included diabetes, hypertension, snoring,sleep apnea, chronic respiratory insufficiency (CRI), chronicbronchitis, cardiac arrhithmia, angina pectoris, varices, axialarthritis, hyperlipidemia, hyperuricemia, hypothyroidism, gas-troesophageal reflux (GERD), depression, and anxiety.Theseaberrations were assessed preoperatively and after 17.6 ± 8.0months, and late results were described as inadequate, partialresponse and total remission. Age of the population was 39.6 ±6.0 years (82.0% females), preoperative BMI was 50.0 ± 8.9and last BMI was 31.7 ± 4.6 kg/m2.
Results: Findings are displayed in the Table as percentage ofthe total population (Pre-op), and as percentage of affectedpatients (Post-op responses).Variable Pre-opInadequate PartialTotal Variable Pre-opInadequatePartial Total RDiabetes 12.0 12.5 29.2 54.2 Varices 8.0 100.0 0 0Hyper-tension 43.0 8.1 27.9 62.9 Arthritis 39.5 10.1 31.6 58.2Snoring 51.5 2.9 19.4 77.7Hyperlipidemia 20.010.0 7.5 82.5Sleepapnea 32.5 0 7.7 92.3 Hyperu
Conclusions: 1) Disappointing outcomes involved varices,hypothyroidism, and anxiety; 2) Very encouraging responseswere seen in face of sleep apnea, chronic respiratory insuffi-ciency, GERD, hyperlipidemia and hyperuricemia; 3) Additionalcomorbidities exhibited moderate improvement.Acknowledgement: The support of FAPESP Grants 00/1609-9and 00/1610-7 is appreciated.
P22.NEW POSITIONING OF THE PORT SYSTEM.Francesco Furbetta, G. Gambinotti.Ospedale di Pescia, Pescia,PT, Italy
Background. The previous vertical positioning of the portresulted, after 4-5 years, in breakage of the port tubing systemin 10-15% of patients. Half of these had to undergo a laparo-scopic procedure under general anesthesia in order to take thetubing out of the abdomen, where it had fallen after breakage(this is considered a major complication).The other half had tohave leakage of the tubing or twisting of the port fixed underlocal anesthesia.The positioning of the port system trans-versely, subcutaneously and parallel to the anterior abdominalwall protects the function and the integrity of the two compo-nents of the system: 1) the port itself and 2) the connectionbetween the port and the tubing.
Methods: Description of the procedure:1) The tubing is takenout from the left anterior axillary trocar hole and, by a ligature,the tubing loop comes out of the left midclavicular trocar hole. 2)After all the trocars have been taken out, the midclavicular tro-car hole has to be enlarged (5cm) towards the midline in orderto contain the port. 3) In this hole 4 nonabsorbable stitches areapplied above the fascia and through the portholes in such away that the port is close to the midline.4) From the extreme lat-eral point of the same hole a curved instrument is introducedand passed above the fascia, coming out in the hole where thetubing comes out. The end of the tubing is grasped and pulledsubcutaneously as far as the site of the port.1)The tubing isconnected to the port. 2) By pulling the loop of the tubing, itcomes into the straight subcutaneous position. 3)The sutures ofthe port are closed. 4)The rest of the loop of the tubing is repo-sitioned in the abdomen.
Results and Conclusion: This positioning permits: easyaccess (anterior m. fascia), durability (4 stitches to the anteriorm. fascia prevent dislocation, well accepted and in a hiddenposition (upper abd. fascia), keeps open the most frequentlyused surgical access points (along the linea alba), does notinterfere with body movements or bending The connection por-tion of the access port system is straight and prevents anybreakage, which in the past was caused by kinking of the tubingvery close to the connector. Our technique avoids the above-mentioned complications and permits easy access to the porttubing system in the subcutaneous under local anesthesia.
P23.MINOR LATE COMPLICATIONS OF ROUX-EN-Y GAS-TRIC BYPASS (RYGBP).Sergio Z. Gil, Monica A. Rudner, Priscilla L.R.C. Machado, JoelFaintuch, Arthur B. Garrido Jr, J.J. Gama-Rodrigues. ObesitySurgery Group, Hospital das Clinicas, Sao Paulo, SP, Brazil
Background: Technical and medical advances in periopera-tive management of bariatric candidates have greatly reducedmorbidity and mortality. However, these severely obese patients
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are still prone to a variety of medium and long-term disorders.Ina prospective study of 200 consecutive subjects, minor com-plaints were systematically registered, aiming to document theirfrequency by 2 years after operation.
Methods: Patients were assessed after 17.6 ± 8.0 months bymeans of a detailed interview, and findings were classifiedaccording to four categories: abdominal wall problems (hernia,eventration), gastrointestinal (GI) abnormalities (vomiting, diar-rhea, flatulence, dumping), nutritional and metabolic aberrations(anemia, hair loss, cramps, hypokalemia, weakness), and mis-cellaneous complaints. Exclusions encompassed manifesta-tions already present before operation, bariatric failure (exces-sive or insufficient weight loss), psycho-social disturbances(anxiety, depression, substance addiction), as well as all acutedisorders requiring immediate investigation or therapeutic inter-vention. Age of the population was 39.6 ± 6.0 years (82.0%females), preoperative BMI was 50.0 ± 8.9 and last BMI was31.7 ± 4.6 kg/m2.
Results: Hernias and eventrations were uncommon (respec-tively 5.5% and 3.0%), and the same was true for GI abnormal-ities except for vomiting, that occurred in 33.5% (dumping in5.5%, diarrhea in 3.0% and flatulence in this same proportion).Among nutritional and metabolic deficits, hair loss was noticedby 28.0%, anemia affected 8.0%, 5.5% had occasional crampsor hypokalemia, and 3.0% complained of weakness.Finally,3.0% each pointed out memory loss and dizziness after RYGBP.
Conclusions: 1) Hair loss is a rarely documented complica-tion but was mentioned by nearly one third of the population,despite routine supplementation of vitamins and minerals; 2)Occasional vomiting was also observed by one third of thegroup; 3) Abdominal wall defects were infrequent, and the samewas true for the remaining investigated abnormalities.
P24.LOWERING THE COMPLICATIONS RATE IN LAP-BANDPROCEDURES BY COOPERATION AND EXPERIENCE.Pavol Holéczy1, Vladimír Medveck2, Albeta Holéczyová1,Linhartová Nadeda1. 1Surgical Department, Railway Hospital,Bratislava, Slovakia 2Surgical Department, VS Hospital, Koice,Slovakia
Background: Our surgical department are the only two inSlovakia performing obesity surgery. The aim of our paper is toanalyse complications in the three groups of patients followinglaparoscopic adjustable gastric banding done for morbide obe-sity. In all the patients the silicone adjustable gastric banding(LAP-BAND , Bioenterics, USA) was used.
Methods: Retrospective analysis of the three groups . Theoperations in the first group were performed from December1997 to December 1999 in Bratislava (36 patients), in the sec-ond group from January 2000 to April 2001 in Koice (16patients) with close cooperation between staff in these two insti-tutions, and the third group in the same time in Bratislava (16patients).
Results: Are listed in the table n=36 n=16 n=16
M : W 11 : 25 2 : 14 3 : 13Age 21 – 55y 19 – 52y 22.50
Conclusion: Complications rate in the first group is ratherhigh. Following the changes in operative technique the resultsbecame better.The results in the second and third group shows,that with gaining and sharing the experience the results couldbe improved.
P25.PROPHYLAXIS OF THROMBOEMBOLISM IN BARI-ATRIC SURGERY.A. S. Lavryk, V. F. Sayenko, O. P. Stetsenko, O. S. Tywonchuk, V.J. Smorzhevsky, O. F. Bubalo. Institute of Surgery &Transplantology Kyiv, Ukraine
Background: Morbidly obese patients have high risk fordevelopment venous thromboembolism.Cause with an extremeweight they are not enough mobile therefore their cardiac, ves-sels and respiratory systems are more vulnerable. Prophylaxisof thromboembolism is very important in bariatric operations.
Methods: Since 1998 we have performed 45 nonadjustableopen gastric banding, 8 adjustable open gastric banding, 2 BPDand 3 RYGB. There are 56 females and 2 males. Weight 95 –187 kg with mean BMI -47, 2 ( 36 –67 ) kg/ m2. Our prophylaxisof venous thromboembolism was combined:intermittent pneu-matic compression,leg elevation,elastic stockings,early ambula-tion. We used low moleculary weight heparins(LMVH): at 30patients –fraxiparine (nadroparinum) – 0,6ml (5700 UI AXa), 18–clexane(lovenox)-enoxaparine – 0,4ml ( 4000 UI AXa) and 10–fragmin (dalteparine) 5000 IE. The standard dose of LMVH hasused as subcutaneous injection 2 hours before operation, thanonce daily from 1 postoperative day before an enough activationof patient (mean – 5 - 7 days ). Also all of our patients havebecomen a pentoxiphyllin i.v. during the 3 postoperative days asan antiaggregate therapy. We performed also 25Trendelenburg‘s procedures and 17 veinectomies as a prelimi-nary operations by patients with a varicose veins. Bariatric pro-cedures carried out by their after 7 days.
Results: We not observe venous and pulmonary thromboem-bolism in any patients.We have not local and systemic haemor-rage complications during LMVH using.
Conclusion: The profilaxis of thromboembolism play an one ofthe main role in surgery especially by bariatric procedures. Weare suggested also that a preliminary operation on veins of lowextremity must done always at patient with varicose.
P26.BODY COMPOSITION STUDIES IN OBESE CHILDREN.Renata B.A. Leme, Marilisa S. Froes, Eduardo Meirelles, Ari L.Cardoso, Andrea Nascimento, Cristiane A.R. Charles, Arthur B.Garrido Jr, Joel Faintuch. Obesity Group, Children`s Instituteand Hospital das Clinicas, Sao Paulo, SP, Brazil
Background: Severe obesity is affecting increasing numbersof young subjects, thus raising the question of body compositionmonitoring in such circumstances.In a prospective study of out-patient children, bioimpedance analysis (BIA) was compared
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with body densitometry (DEXA), aiming to define the bestmethod for assessment of major body compartments in this agegroup.
Methods: The children (n= 41, 9.5 ± 1.3 years, 23 females)had a body mass index of 29.0 ± 6.1 kg/m2. BIA was done bythe classic tetrapolar technique (single frequency) whereasDEXA was obtained in a LUNAR densitometer.Both findingswere compared with standard anthropometric measurementsand growth charts.
Results: BIA indicated body fat of 33.0 ± 12.0% of bodyweight (BW), body water of 48.0 ± 6.0% BW, and body cellmass of 29.0 ± 5.0% BW.These findings were consistent withsome accumulation of body fat, but not as much as clinicallyidentified.At the same time body water and body cell mass wererelatively diminished, but less than expected for the degree ofobesity. DEXA pointed out 47.3 ± 6.9% of body fat, whichclosely matched anthropometric evaluations.
Conclusion: BIA had serious limitations in the investigation ofobese children, whereas DEXA fully corresponded to clinicalassessment.Although it is more expensive, DEXA should be themethod of choice for body composition determinations in thatpopulation.
P27.DOES REDUCTION IN GASTRIC ACID SECRETIONINCREASE THE DAILY ENERGY EXPENDITURE?J.Melissas, E.Kampitakis, G.Schoretsanitis, E.KouroumalisBariatric Unit, Dept.Surgical Oncology, University Hospital,Heraklion Crete Greece.
Background: Aim of this study was to investigate if reductionby pharmaceutical means of gastric Hcl acid secretion is able tolead to significant increase of diet induced thermogenesis(D.I.T), therefore in higher total daily energy expenditure (T.E.E).
Methods: 20 volunteers were included in this study, in each ofwhom resting energy expenditure was measured, by indirectthermidometry, following 12 hours fasting. A standard knowncomposition meal of 1000 Kcal was then given, followed bymeasurement of the energy expenditure (D.I.T) for 0-8 hours.All volunteers were then placed to 150mg Laprasol Per Os dailyfor 2 months. At the end of this period we repeated the mea-surement of R.E.E and D.I.T following the same standard meal.Omeprassol IV 40mg was given I.V. prior to the measurementsin order to further minimize gastric acid secretion.
Results: Statistical analysis of data shows that there are notsignificant changes in both R.E.E and D.I.T following reductionof gastric acid secretion by H2 reseptors antagonists.
Conclusions: Pharmaceutical reduction in gastric acid secre-tion does not significantly increase the T.E.E. Presumably,reduction in gastric acid secretion, as seen following gastricbypass and gastrectomy, is NOT the mechanism of weight lossobserved in these patients. Therefore other mechanismsresponsible for this phenomenon has to be hypothesised andinvestigated.
P28.GASTRO-ESOPHAGEAL REFLUX DISEASE IN OBESEPATIENTS. MODIFICATIONS INDUCED BY BARIATRICSURGERY.Joaquin Ortega, Carlos Sala, Maria Escudero, Francisco Mora,Adolfo Benages, Vicente Sanchiz, Jose Martinez-Valls,Salvador Lledo. Morbid Obesity & Endocrine Surgery Unit,Clinic Hospital and University of Valencia, Valencia, Spain
Background: Obese patients are known to have increasedintra-abdominal pressure causing frequent gastro-esophagealreflux disease (GERD). Bariatric surgery can reduce GERD by
decreasing weight and so intra-abdominal pressure. Dependingon the different techniques performed GERD can also beimproved.
Methods: A total of 138 bariatric procedures were performedbetween 1996 and 2000. Twenty one cases were selected onthe basis of having been performed esophagic pHmetry andmanometry preoperatively, 3 months postop., and 1 year aftersurgery. Techniques performed were: Vertical banded gastro-plasty (VBG) - 7 patients, and Roux-en-Y Gastric Bypass(RYGB)- 14 patients. Data regarding bariatric procedure,Excess Weight loss (%), clinical symptoms of GERD, andresults of esophagic manometry and pH-metry were taken intoaccount. Manometric parameters evaluated were the inferioresophagic sphincter pressure and its total length, wave ampli-tude and % of tertiary activity. pH-metry evaluated parameterswere the percentage of pH<4 in 24-h time and DeMeester test.
Results: Mean excess weight loss at 3 months post-op was46.6 ± 12.3 % for VBG patients and 44.3 ± 7.7 % for RYBGpatients, and at 1 Year post-op was 60.0 ± 9.1 % for VBG and77.3 ± 7.2 % for RYGB, respectively. Results aboutGastroesophageal reflux disease are shown in table below% patients with GERD VBG RYGB
Conclusions: Esophagic pH-metry and manometry are valu-able methods to assess the presence of GERD and thechanges in GERD after bariatric surgery. There is a high preva-lence of GERD in morbid obese patients candidates for surgery.Bariatric procedures can improve GERD in morbid obesepatients. In our experience, the Roux-en-Y Gastric By-Pass isbetter than the Vertical Banded Gastroplasty in reducing GERDwhen it preoperatively exists.
P29.ANASTOMOTIC COMPLICATIONS AFTER ROUX-EN-YGASTRIC BY-PASS FOR MORBID OBESITY: A SAFE PRO-CEDURE..Joaquin Ortega, Carlos Sala, Jose Martinez-Valls, SalvadorLledo.Morbid Obesity & Endocrine Surgery Unit, Clinic Hospitaland University of Valencia, Valencia, Spain
Background: Roux-en-Y Gastric Bypass (RYGB) is consid-ered one of the preferable techniques in bariatric surgery, as itis the gold standard with which other operations should be com-pared. Although it is considered a safe technique with low mor-bidity and mortality rates, anastomotic complications mayappear in the early (leak, hemorrhage) or in the late postopera-tive period (ulcer, stenosis).To evaluate the incidence and treat-ment of choice of anastomotic complications after RYGB formorbid obesity in our series.
Methods: A total of 96 RYGB have been performed from 1997to March 2001. We performed a stapled-transected RYGB withretro-colic and retro-gastric stapled circular (15-mm internaldiameter) side-to-side gastro-jejunal anastomosis and stapledclosure of the jejunal stump. The Roux-en-Y was end-to-sidehandsewn between 150 and 200 cm. depending on the BMI (in7 cases Distal RYGB at 100 from the ileo-cecal valve). Themesenterium opening of the jejunum was always handsewnclosed to avoid internal hernias. Oversuture of the staple lineswere only performed when active bleeding or a closure defectwere present. Gastrograffin Rx check of the anastomosis wasnot routinely performed.
Results. Anastomotic complications are showed on table
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below. Early postoperative complications Late postoperativecomplications Anastomotic bleeding 2 2% Anastomotic stenosis4 4.1% Leak 1 1% Anastomotic ulcer 1 1%. Subphrenic abscess1 1%. One of the two patients whose anastomosis bled requiredsurgical revision after endoscopic failure and persistent shock,and in the operation no active hemorrhage was found.The leakwas suspected due to patient´s early postoperative agitationand tachicardia. After gastrograffin Rx confirmation the patientwas re-operated and the defect at the angle of the reservoir sta-ple line was sutured. The subphrenic abscess was percuta-neously drained, and no enteric comunication could be demon-strated. The 4 anastomotic stenosis were resolved with one-session endoscopic balloon dilatation. The patient with theanastomotic ulcer responded to omeprazol. All patients did wellafter appropriate treatment.
Conclusions: Roux-en-Y Gastric Bypass can be considered asafe operation with a low morbidity rate. In our series, anasto-motic complications were less than a 10%, according to litera-ture reports. In most cases, anastomotic complications can beresolved with non-operative treatment.
P30.PSYCHSOCIAL OUTCOME OF LASGB-OPERATIONSIN ADOLESCENTS.T. Pachinger, F. Schmoeller*. Private practice for clinical psy-chology, Elisabethinen hospital Linz, Department of Surgery*,Austria
Background: Surgical treatment is widely not accepted astherapy for morbidly obese juvenile patients. Nevertheless non-surgical treatment frequently fails to be successful over a longerperiod. Considering especially the severe psychosocial andphysiological consequences of morbid obesity in these patientssurgery seems to be the “last hope“ in special cases .
Methods: In three of 237 patients operated on with LASGB-procedures between XII 1996 and III 2001 we decided to per-form the operation in spite of their age (15, 16, 17 years ) dueto their individual situations. Indications for surgery in thesecases were: familiar history of severe obesity, progressiveweight increase (BMI of 51, 54 and 61), numerous failed non-surgical therapies and weight associated comorbidities. Allpatients had multiple psychosocial problems such as discrimi-nation in social situations, disadvantages concerning schooland job, social isolation, restriction in physical activity and con-sequently loss of self acceptance. In addition to medical obser-vation we performed quality of life questionaires and psycholog-ical interviews in all three adolescents 12-24 mths. postopera-tivly.
Results: All patients reported enormous improvement in lifequality and impact of their psychosocial situation.So far no psy-chological or medical problems occured in these patients. Atpresent each of them is satisfied with the outcome of the oper-ation and would recommend it to other juvenile obese patientsas well.
Conclusion: In special cases LASGB-operations seem to bea therapeutic option for morbidly obese juveniles as well as foradults. In our patients the impact of their psychosocial and phys-ical situation was excellent.
P31.IMPACT OF MINIMALLY INVASIVE SURGICAL FEL-LOWSHIP ON EARLY OUTCOMES IN LAPAROSCOPICBARIATRIC SURGERY.Christine J. Ren MD*, Marina Kurian MD†, Mitchell Roslin MD†and Emma Patterson MD‡. NYU School of Medicine, New York,NY*; Lenox Hill Hospital, New York, NY†; Legacy Health
Systems, Portland OR‡, USABackground: Laparoscopic bariatric surgery requires
advanced laparoscopic skills. The growing demand for laparo-scopic gastric bypass and other minimally invasive bariatric pro-cedures requires training of new physicians and new skill acqui-sition for established bariatric surgeons.The methods availablefor providing this training include minimally invasive surgery fel-lowships with a focus on obesity, weekend courses, proctorassistance and mini-fellowships.The purpose of our submissionis to report our first 10 months of experience following fellowshipin minimally invasive surgery.
Methods: A retrospective review of all laparoscopic bariatricprocedures performed by three surgeons during their first yearof practice.All surgeons successfully completed a one-year clin-ical laparoscopic fellowship that concentrated on bariatricsurgery. Outcomes analyzed were operative time, conversionrate, blood loss, morbidity and mortality.
Results: A total of 85 laparoscopic bariatric operations wereperformed from July 2000 to May 2001 at 3 separate institu-tions, utilizing the same surgical technique. The cases per-formed included: 9 laparoscopic adjustable silicone gastricbandings (LASGB), 66 laparoscopic Roux-en Y gastricbypasses (LRYGB) and 10 laparoscopic biliopancreatic diver-sion with duodenal switch (LBPDDS). There were 74 femalesand 11 males, with a median age of 42 (range 18-66) and aver-age BMI = 49 kg/m2 (range 37-67). The mean operative timewas 202 minutes, (122 minutes- LASGB, 190 min- LRYGB, 299min-LBPDDS). Average estimated blood loss was 110 ml.Therewere 3 conversions (1 LRYGB, 2 LBPDDS) for a rate of 3%;indications included large liver, intra-operative leak and exten-sive adhesions.Length of stay was 1 day for LASGB and 3 daysfor both LRYGB and LBPDDS. There were no mortalities.Majorcomplication rate was 3% and included 1 re-operation for bleed-ing, 1 re-operation for small bowel obstruction and 1 distal anas-tomotic leak which was successfully treated non-operatively.Wound infection rate was 8% and stomal stenosis rate was 8%.
Conclusion: Laparoscopic bariatric operations are complexprocedures that require advanced minimally invasive skills. Ourresults demonstrate that a dedicated training program providesa platform for acceptable early results. The major complicationrate of 3%, even with one year of training, highlights the neces-sity of intensive hands on instruction and questions the ade-quacy of weekend courses as a sole source of education formost physicians.
P32.USE OF BAROS SCORE SYSTEM IN PATIENTS OPER-ATED ON FOR MORBID OBESITY: RESULTS OF OURSERIES.Carlos Sala, Joaquin Ortega, Fernando López, StephanieGarcía, Jose Martinez-Valls, Salvador Lledo. Morbid Obesity &Endocrine Surgery Unit, Clinic Hospital and University ofValencia, Valencia, Spain
Background: The analysis of the results of bariatric surgery isnot only based on weight loss but also includes other aspects ofthe quality of life of these patients such as changes in co-mor-bid conditions.Recently, the B.A.R.O.S. score system has beenaccepted by the Spanish Society of Obesity Surgery as an offi-cial measurement instrument. To evaluate the influence ofbariatric surgery in our patients life using the B.A.R.O.S. scoresystem.
Methods: A total of 93 patients operated on for bariatricsurgery have been followed for more than one year. Operationsperformed include 42 Vertical Banded Gastroplasty (VBG) and
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51 Roux-en-Y Gastric By-pass (RYGB) from 1995 to 2000. AB.A.R.O.S. questionnaire was sent out to all these patients to becompleted and returned.
Results: 90 questionnaires were completed (57 mailreturned, and 33 completed during outpatient visits).The meanfollow-up was 32.7 months for the VBG group, and 18.4 monthsfor the RYGB group. Technique Excellent Very Good Good FairFailure Total acceptable results VBG 21.4% 23.8% 28.6%14.3% 11.9% 73.8% RYGB 37.3% 41.2% 13.7% 5.8% 2%92.2%
Conclusions: A standard measurement system is necessaryto be able to compare different series in bariatric surgery, inorder to evaluate not only the weight reduction but the improv-ing in quality of life. In this field, the results of RYGB appear tobe superior to VBG. Overall, bariatric surgery in our series aregenerally very acceptable.However, weight loss is superior andeasier to keep on RYGB patients, and in our Unit, we nowadaysusually perform RYGB, reserving VBG for only selected cases.
P33.THE LEARNING CURVE IN BARIATRIC SURGERY:IMPLICATIONS IN MORBIDITY AND COSTS.Carlos Sala, Joaquin Ortega, Jose Martinez-Valls, SalvadorLledo. Morbid Obesity & Endocrine Surgery Unit, Clinic Hospitaland University of Valencia, Valencia, Spain
Background: It is widely thought that the larger the experi-ence of the surgeon , the lesser the morbidity in surgery. Thissaying is probably true in many fields of the surgical practice.Surgery for the morbidly obese patient is a recent new field ingeneral surgery, and in many surgical departments has beendeveloped from zero since few years ago. To evaluate the effectof the learning curve in decreasing morbidity and costs inbariatric surgery.
Methods: Since our Unit became involved in bariatric surgeryin 1995 we have performed 138 bariatric procedures, 42 VerticalBanded Gastroplasties (VBG) and 96 Roux-en-Y GastricBypasses (RYGB). To evaluate complications of each proce-dure, patients were divided in two groups, the older and thenewer . To evaluate costs, charts of the first and the last 10 con-secutive patients of each procedure were carefully reviewed.Data regarding operating time, technique, in-hospital stay, andcosts were taken into account.
Results: Table I. ComplicationsTechnique Older NewerVBG N=21 N=21
Conclusions: By the time the bariatric surgeon gains experi-ence a reduction in costs is achieved. Morbidity decreases withthe learning curve, though it does not reach statistical signifi-cance. RYGB is safer and more cost-effective than VBG.
P34.DUODENO-GASTRIC BILE REFLUX AFTER ROUX-EN-Y GASTRIC BYPASS.Magnus Sundbom, Sven Gustavsson. University Hospital,Uppsala, Sweden
Background: Roux-en-y Gastric bypass (RYGBP) leaves theexcluded stomach not readily available for endoscopic or otherexaminations.There are reports on the development of chronicgastritis with intestinal metaplasia in the excluded stomach afterRYGBP. Duodeno-gastric bile reflux (DGBR) has been postu-lated to contribute to gastritis.
Methods: 22 patients (20 females, median (range) age 40(25-50) years) were studied 50 (25 - 75) months after RYGBP.BMI before surgery and at the time of cholescintigraphy was 45(40 - 50 and 29 (19 - 32), respectively. All patients had a stablebody weight. 15 patients had had their gallbladder removed.200MBq 99mTc-labelled mebrofenin was injected intravenously andthe fate of the radioactivity was followed in a computer-assistedgamma camera. Bile flow was enhanced with iv cholecystokinin(75 dog units). 20 MBq Iv 99mTc-pertechnetate was used forlocalisation of the stomach.
Results: Dynamic analysis of stored gamma camera imagesallowed accurate determination of the fate of the tracer in allpatients. 8 patients (36 %) had evidence of DGBR. The mainportion of the tracer was transported in an anal direction and theamount found in the excluded stomach was less than 20%.Repeat examination performed in two patients confirmed thepresence of DGBR. DGBR occurred equally often in patientswith or without scintigraphic evidence of a functioning gall blad-der.
Conclusion: DGBR occurs in 36% after RYGBP irrespectiveof gallbladder status. The role of DGBR for development ofchronic gastritis in the excluded stomach after RYGBP has to beinvestigated further.
P35.BARIATRIC ANALYSIS AND REPORTING OUTCOMESYSTEM FOLLOWING LAPAROSCOPIC ADJUSTABLEGASTRIC BANDING IN FINLAND.Mikael Victorzon, MD, PhD; Pekka Tolonen, MD. Department ofSurgery, Vasa Central Hospital, Vasa, Finland
Background: The reporting on outcome following bariatricprocedures should include changes in co-morbid conditions andquality of life in addition to weight loss. The Bariatric Analysisand Reporting Outcome System (BAROS) seems to provide themeans to fulfil these requests. We have re-evaluated our previ-ously published, initial results of laparoscopic adjustable gastricbanding, using the BAROS.
Methods: Our first 60 consecutive patients were treatedlaparoscopically between the years 1996 and 1999, using theSwedish adjustable gastric band. After a minimum follow-up of³ 17 months (median follow-up 28 months, range 17 - 61months) a postal questionnaire concerning quality of life, med-ical condition and excess weight loss (BAROS) was sent to the
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patients. In addition, the patients opinion regarding the opera-tion was evaluated as well as to which extent the band hadcaused the patients any of the commonest side effects.
Results: 87% of the patients returned the questionnaire prop-erly answered. According to BAROS, the outcome wasregarded as FAILURE in 21% of cases, as FAIR in 29%, asGOOD in 38% and as VERY GOOD in 12%. Not one had anEXCELLENT outcome. 23% of the patients were disappointedwith their operation. The incidence of band related side effectswas high.
Conclusion: Our results are comparable with other publishedseries including the learning curve. In our opinion BAROSshould be widely adopted.
P36.REMIFENTANIL ANESTHESIA CAN REDUCE THE CON-SUMTION PERIOPERATIVE INTRAVENOUS MORFINE INBILIOPANCREATIC SURGERY IN MORBID OBESE.M. A. Villanueva, F. J. Barredo, A. Muñecas, S. G.Santos, A.Dominguez, F. C. Escalante. S Anestesiología y ReanimaciónHosp Univ Marqués de Valdecilla. Santander, Cantabria Spain
Background: Postoperative pain control is one of the mostimportant goal in the postoperative period following biliopancre-atic surgery because the surgery can be painless and an inef-fective pain control may lead to serious complications. Theoptions for pain management including systemic analgesics (NAIDS and opioids) and neuroaxial opioids and local anesthet-ics which can be very dificult to do in the morbid obese patient.Remifentanil is a new opioid with a short duration of action andexcellent recovery used during anesthesia for especially situa-tions like the mobid obese
Methods: 20 consenting morbidily obese patients sheduledfor elective biliopancreatic bypass participated in the study. Allpatients were anesthetized with the same anesthetic regime,which included propofol, rocuronio, sevoflorane. To 10 patientswere administred fentanil and the others remifentanil for intra-operative analgesia. The postoperative analgesia regimen waseffective in all patients and consisted in NAIDS + TRAMADOL +Morfina in PCA. We compare consumption of morfina in bothgroups of patients 24 after surgery
Results: All patients were a good pain score in visual ana-logue score (VAS) at rest and were able to sit in a chair a 18hours after surgery. 24 hours after surgery the patients weredoing exercices for their breath and cough, they getting asleepsometimes, rarely they have nausea and vomiting, and the post-operative consumption of morfina in the group of remifentanil 24h after surgey were 20 mg while the needs of morfina in thegroup of fentanil were 32.84 mg.
Conclusion: Morfina is a good amalgesic but their side effectsin the repiratory and gastrointestinal system in morbid obesepatients schedule to abdominal surgery must be consideredReduction in consumption of morfina 24 hours after surgery canbe because the first dosis before the surgery is finish is larger ingroup of remifentanil or because with remifentanil is achieved abetter control of stimulus nociceptive during surgery.
P37.COMPARISON OF RESPIRATORY FUNCTION TESTSAFTER TWO DIFFERENT ANESTHETIC TECHNIQUES FOL-LOWING LAPARASCOPIC MORBID OBESITY SURGERY.Ziya Salihoglu*, Kagan Zengin**, Sener Demiroluk, OktayDemirkiran*, Yildiz Kose*, Mustafa Taskin** University ofIstanbul, Medical Faculty of Cerrahpasa, Department ofAnesthesiology* and General Surgery**, Istanbul, Turkey
Background: To choice of anesthetic technique for general
anesthesia in morbidly obese patients remains controversial (1).Arterial oxygenation may be extremely impaired during andafter surgery (2). Generally, TIVA with propofol and sevorane isused for anesthesia management. Inhalation anesthetics suchas sevoflurane have some bronchodilatatory effects. Otherhand, especially one-lung ventilation protocols showed that pO2level with using propofol were greater than inhalation anesthet-ics (2). Propofol may provide lower shunt fraction values thansevoflurane (2).
The aim of this study was to investigate respiratory functiontests after two different anesthetic techniques and determinedconvenient technique for laparascopic morbid obesity surgery.
Method: Thirty patients were studied in two randomizedgroups (n=15 each). Patients were distributed randomly into twogroups as; Patients receiving totally intravenous anaesthesia(TIVA) which is group T, and the others receiving sevoflurane asgroup S. All of the patients were morbidly obese patients andthey went under laparascopic stoma-regulated gastric bandageoperation. Respiratory functional tests (FVC, FEV1, FE1/FVC,FEF 25-100, PEF) were performed 1 day before operation (1measure) and postoperative 2. day (2 measure).Student’s t testwas used for data analysis.P value smaller than 0.05 were con-sidered statistically significant.
Results: Respiratory tests reduced after the operation in bothgroups(p<0.05).Whereas In the group T; tests were determinedsignificantly lower than group S (p<0.05).Results:
FVC FEV11measure 2measure 1measure 2measure
Group 88.7±23.9 71.66±21.1*† 88±22.1 66.8±19*†Group S 93.4±11.5* 90.3±11.5 92.7±12.1 88.06±11*
Group 91.6±84.6 84.6±18.3Group S 89.3±14.6 84.1±17.3
Conclusion: It is concluded that, postoperative respiratorytests were better with sevoflurane compared propofol, when itwas used as an anesthetic maintenance, during laparascopicmorbid obesity surgery.
P38.CONVERSION OF FAILED VERTICAL BANDED GAS-TROPLASTY (VBG) TO OPEN ADJUSTABLE SILICONEGASTRIC BANDING (ASGB).Mustafa Taskin*, Kagan Zengin*, Ethem UnalL*, ZiyaSalihoglu**. University of Istanbul, Medical Faculty ofCerrahpasa, Department of General Surgery*, Anesthesiology**, Istanbul, Turkey
Background: An increasing number of patients with failedVBG procedure present themselves for secondary treatment.The reoperations in these failed cases can be tried with ASGB
Methods: During the period 1991-1997, at General SurgeryClinic of Cerrahpa?a School of Medicine in Istanbul, 80 morbidlyobese patients were managed surgically with VBG. In 7 of themthe staple line disruption and weight gaining were detectedwithin 3 year (24-48 months) control period. A conversion pro-cedure to ASGB was applied between 1994-1998. Meanwhileanother 80 morbid obese patients were operated with openASGB technique.
Results: In 7 patients (8.75%) staple line disruption appeared
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on the radiography as leakage of the contrast material. Afterconversion of the failed VBG cases to ASGB procedure, theearly postoperative characteristics were very satisfactory andsimilar to those of our open ASGB-applied group.
Conslusions: VBG is a safe technique although reoperationand conversion rates are high. Staple line disruption constitutesthe chief cause of insufficient weight loss and frequently indi-cates the need for further surgery. Our early results of the revi-sional surgery confirm that the reoperations in failed VBG casescan be tried with ASGB technique.
P39.BAND EROSIONS FOLLOWING ADJUSTABLE SILI-CONE GASTRIC BANDING(ASGB) FOR MORBID OBESITY.Mustafa Taskin*, Kagan Zengin*, Ethem Unal*, Ziya Salihoglu**.University of Istanbul, Medical Faculty of Cerrahpasa,Department of General Surgery* and Anesthesiology**,Istanbul, Turkey.
Background: Adjustable slicone gastric banding (ASGB)technique has been advocated as a minimally invasive proce-dure that is a completely reversible for the surgical treatment ofmorbid obesity. One of the possible complications of ASGB isband erosion(BE).The aim of this article is to present our expe-rience with BE and discuss its possible causes.
Methods: We performed 165 operations (112 women and 53men) from december 1994 to june 2000 , 85 of which were bylaporoscopy. The average lenght of following period is 3 years(3-52 months)
Results: In the examinations of patients with insufficientweight loss and excessive vomiting , by double- contrast radi-ography and endoscopy , BE was fond in 3 female patients(1.81%). Their bands removed by open approach.
Conclusions: Band erosion is one of the possible complica-tions after ASGB. It usually develops at least several months fol-lowing operation. It should be prevented by placing the bandcorrectly and keeping away from infection the only treatment ofBE is removal of the band.
P40.EFFECT OF POSITION CHANGES AND PNEUMOPERI-TONEUM ON RESPIRATORY MECHANICS IN THE LAPARO-SCOPIC MORBID OBESITY SURGERY.Ziya Salihoglu*, Kagan Zengin**, Sener Demiroluk*, SerpilCakmakkaya*, Yildiz Kose*, Mustafa Taskin** University ofIstanbul, Medical Faculty of Cerrahpasa, Department ofAnesthesiology* and General Surgery**, Istanbul, Trukey.
Background: In the laparoscopic operations for morbid obe-sity surgery, position changes were performed to exposure andaccess to surgical site. The aim of our study was to evaluatepneumoperitoneum (PP) and position changes on respiratorymechanics during the operation period.
Method: ASA I-II groups of 11 patients were included in thestudy. All of the patients were morbidly obese patients and theywent under laparascopic stoma-regulated gastric bandageoperation.Ventilation was controlled artificially.Tidal volume andventilator frequency was kept constant throughout the opera-tion. Intraabdominal pressure was hold up to 16 mmHg. Ventrakrespiratory mechanic (Model 1150, USA) device was used formeasure to respiratory mechanics. Expiratory volume (EV),resistance of airway (Raw), compliance (C), peak inspiratorypressure (PIP) was measured.Measuring was performed in fourperiods. [Supine position (SP) (1 measure), after PP with SP (2measure), at 30 degree head up position with PP (3 measure),at 30 degree BC with desufflation (4 measure)].Repeated mea-sure ANOVA was conducted on data. P smaller than 0.05 were
considered statistically significant.Results:Table I: Respiratory mechanic values
Conclusion: The negative effect of PP was balanced from thepositive effect of head up position, at the end of PP providingSP, Raw and PIP of C was turned back to normal. Also C get-ting better but remains lower than 1 measure.
P41.LEARNING CURVE OF THE SURGICAL TREATMENT INMORBID OBESITY.A. Bozbora*, Y. Erbil*, S. Ozarmagan*, U. Barbaros*, N. Ozbey**,Y. Orhan**. *Department Of General Surgery, Istanbul MedicalFaculty, Istanbul, Turkey, ** Deparment Of Internal Medicine,Istanbul Medical Faculty, Istanbul, Turkey
Background: With the experience of seven years in morbidobesity surgery, we tried to evaluate the most probable prob-lems of the surgeons who have already started to perform mor-bid obesity surgery. We believe that the surgical team that willwork on morbid obesity surgery should be well qualified in thefields of gastrointestinal surgery, endocrinology and humanmetabolism. Also laparoscopic experience is obligatory toachieve the success in laparoscopic morbid obesity surgery.
Methods: In our patient group, AGSB (Adjustable GastricSilicone Banding) has been performed in 33 patients. In 5patients, VBG ( Vertical Band Gastroplasty) technique has beenperformed. Mean age of the patients was 31 years(23-44). 24patients were female, 14 were male.The mean BMI was 41 (36-48). Laparoscopic procedures were performed in 12 patients. In6 patients, we started operation laparoscopically but continuedand ended the procedure with open surgical techniques. Themean operation time 180 minutes in laparoscopic proceduresand 56 minutes in open surgical techniques.
Results: The mean preoperative weight of the patients were130 kg (94-189). During follow up of the patients in postopera-tive period, except 3 of them all patients had decreasement intheir BMI. Over all, mean hospital stay of the patients were 4days. As postoperative complication, we mostly detected woundinfection in 7 % of patients.Respiratory infection rate was 3.4 %.In a patient we diagnosed Wernicke’s encephalopathy and gas-tric erosion due to band in another patient.
Conclusion: Morbid obesity treatment with surgical proce-dures should be managed by team composed of general sur-geon, anesthesiologist, endocrinologist and a phyciatrist. Thesurgeons who have enough experience in open surgical proce-dures of morbid obesity, usually perform laparoscopic proce-dures more easily. The most common problem encountered wasthat the doctors and the patients generally have insufficient andfalse knowledge about the morbid obesity surgery. Also resultsand complications of the old surgical methods used in morbidobesity surgery have negative effects on ideas of patients aboutnew surgical techniques.The surgeons who will be interested inmorbid surgery should be ready to struggle with the wronglyand insufficiently informed patient group and lack of enoughfinancial sources.
P42.REOPERATIONS AFTER LAPAROSCOPIC ADJUST-ABLE SILICONE GASTRIC BANDING (LAP-BAND®BIOENTERICS-MCGHAN).U. Elmore, A. Restuccia, N. Perrotta, D. Polito*, E. Bianchi**, N.
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Lo Martire**, G. Silecchia, N. Basso. Dipartimento di chirurgia“Paride Stefanini”- Policlinico “Umberto I” Università “LaSapienza” Roma”, *ASL Roma G, **ASL Frosinone PresidioSora, Italy
Background: In a recent review the reported reoperation rateafter LASGB ranged between 3.8 % and10.5%.The aim of thepresent study was evaluate the reoperation rate after LASGBand the related causes.
Methods: From January ‘96 and April ‘01, 34 patients under-gone LASGB (Lap-Band® Bioenterics-McGhan), 2 of themreferred to our center, were reoperated under general anesthe-sia. Other 8 patients experienced reservoir treated under localanesthesia in ambulatory setting.
Results: the causes of the reoperations, the procedures andkind of anesthesia performed are following showed: irreversiblepouch dilatation (4 pts) laparoscopic band removal under gen-eral ansthesia; intragastric band migration (14 pts) minimallyinvasive band removal under general anesthesia;psychologicalproblems (5 pts) laparoscopic band removal under generalanesthesia; intraperitoneal band system rupture (2) laparo-scopic catheter connection under general anesthesia;port com-plications (7 pts) removal/substitution under local anesthe-sia. Mortality was nil; mean operative time was 70 minutes;wound infection occurred in 2 cases (intragastric band migra-tion); mean hospital stay was 4 days.
Conclusions: Reoperation rate in our experience was 9% andthe main reason was intragastric band migration (8.5%). All thereoperations requiring general anesthesia were performed byminimally-invasive approach, outlining the reversibility ofLASGB also in case of intragastric band migration.
P43.BIOENTERICS INTRAGASTRIC BALLOON; A NONAGGRESSIVE SOLUTION FOR THE TREATMENT OF THEOBESITY?J. Herve, C. H. Wahlen, B. Bastens, B. Dallemagne, C. Jehaes,J. L. Jourdan, S. Markiewicz, J. Weerts. Les Cliniques SaintJoseph, Liege, Belgium
Background: The concept of using gastric space-occupyingvolume devices for the control of obesity was first described in1982.
Methods: We propose here a study including 320 BIB placedconsecutively to analyse its efficacy in the treatment of obesity,its complications and side effects.
Results: Of the 320 patients, 54 were males and 266 werefemales ( Sex Ratio H/F:1/4.9); the mean age was 42 years(range 16-71); the mean BMI was 35 (range 28-51) .Our inclusion criteria were: morbid obesity ( BMI > 40 ) in 46patients, grade II obesity ( BMI 35-40) in 114 patients and gradeI ( BMI < 35 ) obesity in 160 patients. The mean balloon fillingwas 529 ml ( 400-700) of sterile saline in which 2 ml of methyl-ene blue has been added.The mean implantation of the balloonin the gastric cavity was 35.42 weeks. Mean weight loss was14.7 kg ( range –45 to +18). Mean male weight loss was 16.4 kg( 0-45), and female was 14.32 kg ( -44 to +18). Mean BMI reduc-tion was 4.85 ( -18 to +7). Concerning complications, weobserved;no death, peptic ulcer; 3.75 % ( 12 cases) , esophagi-tis; 4.69 % ( 15 cases), intestinal occlusions 0.94 % ( 3 cases,all treated by laparoscopic surgery) , 2 cases of infection whichinduced a “mega-balloon”with a hydro-aeric level and one caseof gastric haemorrhage.During the first week after implantation,about one third of our patients ( 100/320) didn’t feel anything.Nausea and vomiting were present in 141/320 cases (44%),epigastric cramps; 84/320 (26.2%) and reflux ; 66/320 (20.6%).
In one case the physical intolerance needed to remove the BIBafter three weeks implantation. After more than two weeks 102of our 320 patients didn’t feel anything, nausea and vomitingwere observed in 92 patients (28.75 %) and we hospitalized 17patients and treated for dehydration.
Conclusion: We believe that the BioEnteric’s IntragastricBalloon can be considered a safe and valid method for obtain-ing good weight loss, if associated with restricted diet, a multi-disciplinary approach and a good collaboration and motivationof the patient.
P44.SHORT-TERM BODY COMPOSITION FOLOWINGLAPAROSCOPIC ADJUSTABLE SILICONE GASTRIC BAND-ING.A Diez-Caballero, J. Gómez-Ambrosi, I. Monreal, J. Salvador, J.A. Cienfuegos, G. frühbeck. Depts. Of Surgery,Endocrinologyand Biochemistry,Clínica Universitaria de Navarra-MetabolicResearch Labaratory,University of Navarra,Pamplona ,Spain
Surgery is the most effective therapeutical option for weightreduction in carefully selected patients with morbid obesity,which is resistant to conventional treatment. Considerableprogress has been made in developing safer and less invasiveprocedures foe promoting weight loss.The goal of the present-ing study was to determine weight, body composition as well asmetabolic and hormonal changes in the early period of rapidweight loss.
Thirteen male morbidly obese patients (mean age:33.4±3.2years) undergoing laparoscopic adjustable silicone gastricbanding (LASGB) were evaluated before and three months afterBariatric surgery. Changes in body composition were assessedby the whole body air-displacement method (BOD POD; LifeMeasurement Instruments, Concord, CA).Blood analysisincluded the measurement of glucose, triglycerides, HDL-chole-strol, LDL-cholestrol, insulin, leptin and cortisol concentrations.Already 3 months after LASGB all measurements performedshowed a statistically significant improvement (P=0.0001 for allexcept for cortisol concentrations P=0.0020-Wilcoxon test).Mean weight loss was 18.5±8.3 kg with 10.6±3.7 kg corre-sponding to fat reduction.
Therefore, approximately 57.3% of the total weight lossobserved was attributable to the decrease of the fat compart-ment.Time Weight (kg) BMI (kg/m2) Fat (%) Fat (kg) Fat free mass (%)Before 133.9± 6.5 46.0±2.5 42.7±1.8 55.5±3.7 57.3±1.8After 3 mo113.7±4.9 38.5±1.9 38.4±2.4 44.3±4.4 61.0±2.3
Time Glucose Triglycerides HDL LDL(mg/dl) (mg/dl) chol(mg/dl) chol(mg/dl)
Before 115.6± 8.0 145.2±21.6 41.5±1.9 146.8±9.4After 3 mo 94.4±4.6 105.1±25.5 46.1±3.7 134.4±12.1
Time Insulin (UI/l) Leptin (?g/l) Cortisol (?g/dl)Before 49.0± 9.1 37.7±6.1 23.0±3.3After 3 mo 23.9±5.5 26.7±4.3 6.4±1.1
These findings show the importance of performing body com-position measurements during rapid weight loss after Bariatricsurgery to monitor the changes taking place in the fat free massin order to encourage patients to maintain or even increase thelean mass.
P45.LAPAROSCOPIC GASTRIC BYPASS FOR MORBIDOBESITY: FIRST EXPERIENCE WITH 15 CASES.M. Weber1; M.K. Müller1, F. Horber2, L. Krähenbühl1; R. S.Hauser3. 1University Hospital Zürich; Clinic for Visceral Surgery,Zürich, Switzerland, 2Klinik Hirslanden, Zürich, Switzerland,
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3Consultant for Nutrition, Zürich, SwitzerlandBackground: There is increasing evidence that the laparo-
scopic gastric banding is not ideal for all patients with morbidobesity such as for patients with severe eating disorders, withesophageal dismotility or with a body mass index (BMI) >50kg/m2. A combined malabsorptive-restrictive procedure like thelaparoscopic gastric bypass might be an attractive alternativefor those patients. The aim of our study is to analyze our firstexperience with this procedure and to report the feasibility of alaparoscopic conversion from the gastric banding to the gastricbypass.
Methods: Since June 2000, 15 patients underwent a laparo-scopic gastric bypass at our clinic. All data were collectedprospectively. Indications were a BMI >50 kg/m2 (4 patients),Eating-Disorder (6 patients), failure of a previous gastric band-ing (3 patients), or an insufficient lower esophageal sphincter (2patients).
Results: 14 operations were conducted laparoscopically, onehad to be converted to open surgery (6.6%). The average timeof operation was 298 min (150-480). Early complications con-sisted of three subcutaneous wound infections and one gastricemptying disorder, all of which were treated conservatively.Average hospital stay was 12.6 days (7-24). Early follow-upshowed a BMI reduction from 45.8 to 36.4 kg/m2 during the first2 months. A decrease of the BMI from 40 to 28 kg/m2 over 6months was observed in the first 2 patients.
Conclusion: The laparoscopic gastric bypass is in our experi-ence a method with a low morbidity. This procedure offers asuperb therapeutic option in patients whit contra-indications forpure restrictive methods, and moreover, it might be the only effi-cient choice for the increasing number of patients with failedlaparoscopic gastric banding.
P46.ESOPHAGEAL DILATATION FOLLOWING LAPARO-SCOPIC ADJUSTABLE SILICONE GASTRIC BANDING.Dorothy R. Ferraro, MS, CS, ANP, Richard B. Rubenstein, MD,Stuart Katz, MD. Private Practice, Caremax Wellness andWeight Management Center, E. Patchogue, N.Y., USA
Background: Laparoscopic adjustable silicone banding(LASGB) is currently being studied in the United States and hasbeen in widespread use in Europe, Australia and Mexico for thepast several years. Complications associated with LASGB havebeen reported to include pouch enlargement, band slippage,band erosion, infection (Belachew, 1998), and port or catheterleakage (Miller,1999). Sugarman, 2000, reported esophagealdilatation in 72% of his patients following LASGB with theLapBand. The purpose of this study was to analyze our experi-ence with a group of LASGB patients and compare them toRoux-en-Y Gastric Bypass (RNYGB) and Vertical BandedGastroplasty (VBG) patients with regard to esophageal dilata-tion..
Methods: Twenty-seven patients were randomly selectedfrom our practice. Preoperative upper GI series were comparedto a follow-up study performed an average of one year postop-eratively.The radiological studies were independently analyzedby a radiologist who determined the measurements and judge-ments regarding esophageal diameter, esophageal fullness,and stoma size.The esophageal diameter was measured in theRAO and LAO views and an average of the two values wasdetermined. The radiologist provided an overall judgement ofthe esophageal size using a scoring system, and based this onhis visual determination of the degree of esophageal fullness.A30 percent or greater change in esophageal diameter was con-
sidered significant.Results: Two of the ten patients in the LASGB group were
found to have both quantitative esophageal dilatation and visualesophageal fullness; two additional patients had visualesophageal fullness. All four of these patients were noted tohave a maximally restricted stoma. There was no significantchange in esophageal diameter postoperatively in RNYGB andVBG group. One patient reported to have mild esophageal full-ness following RNYGB was also found to have a maximallyrestricted stoma. In the VBG group, one of nine patients wasfound to have mild esophageal dilatation and fullness postoper-atively with a normal stoma size.
Conclusion: Esophageal dilatation and fullness in LASGBpatients in this study consistently correlated with maximalstomal restriction. This represents a marker for stomal restric-tion which is too extreme on a chronic basis. With mild or mod-erate degrees of LapBand restriction, there is no evidence ofesophageal dilatation or fullness.
P47.LAPAROSCOPIC GASTRIC BANDING: THE LONGISLAND EXPERIENCE.Dorothy R. Ferraro, MS, CS, ANP, Richard B. Rubenstein, MD.Private Practice: Caremax Wellness and Weight ManagementCenter, E. Patchogue, N.Y., USA
Background: Laparoscopic adjustable silicone gastric band-ing (LASGB) has recently been introduced as a minimally inva-sive approach to the treatment of medically severe obesity.Clinical trials are currently being conducted in the United Stateson LASGB with the LapBand. Thirty-one procedures were per-formed between March and December of 1999 on Long Island.
Methods: Patients who met FDA-approved criteria were eval-uated by a multidisciplinary team preoperatively to determinetheir overall appropriateness for surgery. Dietary, exercise andbehavioral counseling were provided to all patients pre- andpostoperatively. Patients were followed for a twelve-monthperiod following surgery; most were monitored monthly.
Results: Thirty-one patients, aged 22 to 56, with a mean bodymass index of 47.4, underwent LASGB with the LapBand. Meanduration of surgery was 187 minutes (range 88-355 min); nonerequired open conversion. One patient underwent concomitantcholecystectomy. Average length of hospital stay was 1.5 days.There were no serious early postoperative complications. Onepatient was lost to follow-up. Two patients developed late post-operative complications requiring removal of the LapBand (onewith band erosion, the other with infection).The average excessweight loss at twelve months was 37.6 percent (range 10-65%).
Conclusion: LASGB with the LapBand is a safe and effectivesurgical option for the management of medically severe obesity.
P48.DISSOCIATION OF PLASMA LEPTIN CONCENTRA-TIONS WITH INSULIN AND BODY FAT 24 HOURS AFTERLAPAROSCOPIC ADJUSTABLE GASTRIC BANDING.Frühbeck G, Diez-Caballero A, Gómez-Ambrosi J, Monreal I,Salvador J, Cienfuegos JA. Depts. of Surgery, Endocrinologyand Biochemistry, Clínica Universitaria de Navarra, MetabolicResearch Laboratory, University of Navarra, Pamplona, Spain
The adipocyte-derived hormone, leptin, has been shown todecrease both food intake and body weight. Circulating leptinconcentrations are associated with plasma insulin and body fat.Gastric banding represents a surgical procedure designed pri-marily to reduce food intake.The placement of an adjustable sil-icone band in order to obtain a reduced stomach pouch hasbeen reported to produce an early satiety sensation in patients
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undergoing gastric banding. The aim of the present study wasto assess the potential involvement of acute changes in leptinconcentrations following laparoscopic adjustable silicone gastricbanding(LASGB).
The study groups comprised male patients undergoing eitherLASGB (age: 46±13 years; BMI: 43.0±2.5 kg/m2; body fat:40.3±4.4%; n=7) or a comparable procedure regarding the sur-gical approach as well as the time and kind of manipulationslike laparoscopic Nissen fundoplication and laparoscopichernioplasty (Fd/Hn) (age: 50±8 years; BMI: 26.1±1.6 kg/m2;body fat: 27.8±6.6%; n=6).Blood was withdrawn before surgeryand 24 hours postoperatively for glucose, insulin and leptinmeasurements.In both experimental groups no statistically sig-nificant changes were observed in pre-and postsurgery glucose(LASGB: 111±8 vs 99±6 mg/dl; Fn/Hn:107±7 vs 98±5 mg/dl)and insulin concentrations (LASGB: 39.8±11.9 vs 32.9±10.3U/l;Fn/Hn;13.2±3.3 vs 12.2±2.9 U/l).However , following surgeryan increase in leptin concentrations was observed in theLASGB group(23.5±4.7 vs 37.5±6.8 _g/l) whereas a smalldecrease was evident in the Fn/Hn patients (12.9±4.6 vs8.9±2.2 _g/l). These findings strongly suggest that the shortterm increase observed in plasma leptin concentrations follow-ing LASGB may play a key role in triggering an early satiety sig-nal due to the modification of the gastrointestinal anatomy andphysiology.
P49.UNILATERAL LOWER EXTREMITY COMPARTMENTSYNDROME FOLLOWING A LAPAROSCOPIC ROUX-EN-YGASTRIC BYPASS. A CASE REPORT.Piotr J. Gorecki, MD, Daniel Cottam, MD, L. D. George Angus,MD, Ralph Ger, MD, Gerald W. Shaftan, MD. Nassau UniversityMedical Center, East Meadow, NY, USA
Background: Obesity surgery has the potential for seriouscomplications.We present a case of unilateral lower extremitycompartment syndrome after a laparoscopic gastric bypass per-formed in the modified lithotomy position.
Case report: A 38 year old female (weight - 134.5 kg, BMI –49.6) underwent a laparoscopic Roux-en-Y gastric bypass(operating time - 375 min). Following recovery from generalanesthesia the patient complained of bilateral lower extremitypain, which was subsiding and the patient was able to ambulateon the night of surgery. On a postoperative day one, however,she developed a right leg compartment syndrome (compart-ment pressure – 71 mm of Hg). The patient underwent fas-ciotomy of the anterior and lateral compartments.Her pain sub-sided and the small area of numbness on the dorsum of the footimproved. On the following day, the patient was ambulatingwithout difficulty and was discharged home on a fifth postoper-ative day. By the 12th postoperative day her fasciotomy woundwas closed with an assistance of a novel device (Proxiderm) byapplying a constant tension on the wound edges, which enableddelayed primary closure. The subsequent recovery wasuneventful and her right leg recovered without any motor or sen-sory deficits. At 4-months follow-up she had a weight loss of 28kg, stayed physically active and was overall satisfied with hersurgery. Potential pathomechanisms and risk factors are high-lighted. Review of the literature is provided.
Conclusion: Bariatric surgeons should be aware of this rarecomplication. Prevention and early recognition of this potentialcomplication and prompt fasciotomy are crucial for favorableoutcome.
P50.MANAGEMENT AND THERAPY OF POSTOPERATIVE
COMPLICATIONS AFTER GASTRIC BANDING FOR MOR-BID OBESITY.U. Winterberg, D. Wagner, H. Bockhorn. Chirurgische KlinikKrankenhaus Nordwest Frankfurt am Main, Germany
Laparoscopic gastric banding has become a common proce-dure in bariatric surgery.Early as well as late complications are,in comparison to conventional techniques, rare. Complcationsarising from the operative technique are:perforation,early pouchdilatation, gastric slippage, infections of the port and the band,erosion and defects of the band tube.Insufficent weight loss andlate pouch dilatation arise from unsatisfactory compliance onthe part of the patient.After 464 operations in 7,8 % reopera-tions were necessary.Obstruction of the pouch stoma and slip-page resulted in total food intolerance.The management,diag-nosis and therapy of the common complications after gastricbanding is presented.
P51.LAPAROSCOPIC ROUX EN Y GASTRIC BYPASS WITHSILASTIC RING (CAPELLA´S PROCEDURE) IN THE TREAT-MENT OF MORBID OBESITY : EARLY RESULTS AND COM-PARISON TO TECHNIQUE WITHOUT SILASTIC RING.Thomas Szegö, MD, PhD ;Arthur B. Garrido Jr. MD, PhD;Mitsunori Matsuda, MD, PhD.; Carlos José Lazzarini Mendes,MD; Marcelo Roque de Oliveira, MD; Alexandre Elias, MD, LuizVicente Berti, MD. Private Practice - Albert Einstein andBeneficência Portuguesa Hospital, São Paulo, Brazil
The introduction of laparoscopic approach to bariatricsurgery brought similar advantages as seen in general surgery.Performing Roux en Y gastric bypass according to the regulartechniques however, showed less weight loss then achieved inthe open procedure using silastic ring. In order to get similarresults as in open Capella´s procedure, the authors introducedsimilar technique through laparoscopic aproach. Patients under55 in BMI are selected to open or laparoscopic procedure.Theauthor´s compare the early results of laparoscopic procedurewith and without silastic ring.
The results shows that the complementation of the operationwith silastic ring didn´t make the operation more difficult or timeconsuming, didn´t increased complication rates and, in early fol-low up period, the patients had more regular and higher weightloss.
P52.MANAGEMENT OF BILIOPANCREATIC DIVERSIONCOMPLICATIONS.Santo Bressani Doldi, G. Micheletto, M. Perrini, E. Mozzi.Cattedra di Chirurgia Generale dell’Università degli Studi diMilano - Istituto Clinico Sant’Ambrogio; Centro per laFarmacoterapia delle Malattie Nutrizionali e Metaboliche “E.Genovese e R. Klinger”, Milan, Italy
Background: In our Centre of bariatric surgery, active since1974, we have never utilized the biliopancreatic diversion (BPD)for its incomplete reversibility and its surgical aggressivenessbut, from the beginning of 80’s, we have hospitalized for severecomplications 20 patients who underwent this procedure in dif-ferent centres and in different times. Here, we report our expe-rience of management of BPD complications, particularly withreference to the last 7 patients treated in the last 3 years.All thepatients were operated on the same type of BPD.
Methods: The patients are all females, mean age 42.5 years(25 – 47); mean weight pre-BPD 92.5 Kg (82 – 114); meanweight at the moment of hospitalization 65 Kg (55-89); meanBMI pre-BPD 35,6 (34 – 45); mean BMI at the moment of thehospitalization 25,3 (20 – 36); mean follow-up 9,5 years (2 - 17).
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We observed these complications: insufficient weight loss (1patient : from 91 to 89 Kg); excessive weight loss for persistentmalabsorption ( 3 pts); severe osteomalacia for alteration of cal-cium and vitamin D metabolism (2 patients), 1 with spontaneouspertrocanteric fractures; severe hypoproteinemia ( 7 pts ); irondeficiency anaemia ( 6 pts). One patient had numeroushaematic transfusions; severe and late dumping syndrome (1pt); halitosis (3 pts); persistent diarrhea more than 5 evacua-tions/day (1 pt); liver failure (1 pt). Six patients were treated withhyperproteic and hypercaloric parenteral nutrition (PN), andwith polyelectrolytes and polyvitaminics endovenous infusion formore than 60 days, in the hospital and/or at home, till to gain anacceptable metabolic balance.We have converted 3 patients toadjustable gastric banding according to Kuzmak and 2 patientshad reversal; the others are still under medical care.
Results: Hyperproteic and hypercaloric parental and oralnutrition obtained in all patients a good metabolic balance.Three patients didn’t achieve a stable metabolic balance at theend of PN so that it was necessary a reversal of BPD or con-version to adjustable gastric banding in accordance with thepatient, the internist and the psychologist. One patient hadreversal for psychological indication. Post-operative course wasuneventfull for 2 patients; 1 patient had an acute hemorrhagicgastritis in the first post-operative day, treated with medical care.One patient had a revision for intestinal occlusion. The patientwho had an insufficient weight loss after BPD, had a good resultafter adjustable gastric banding (from 89 to 70 Kg, BMI 25).Theother patients had an increase of 20 Kg one year after reversal.
Conclusion: Our experience permits to underline that: 1) BPDcan be better used in the morbidly obese patients with BMI > 40;2) the choise of the patients must be careful, particulary by psy-chological point of view; 3) BPD requires a continous, constantand rigorous follow-up to prevent or to opportunely treat themetabolic complications such as all malabsorption bariatric pro-cedures. These all complications can be successfully traitedmedically or surgically; 4) BPD doesn’t permit the completereversibility because of gastrectomy but only a partial functionalone; 5) the metabolic complications and the failures of BPD canbe treated by conversion into adjustable gastric banding.
P53.PRELIMINARY STUDY CONCERNING A SINGLE INSTI-TUTION’S EXPERIENCE WITH 1410 CASES OFADJUSTABLE GASTRIC BANDING PERFORMED FROMJULY 1995 TO APRIL 2001, (5-year retrospective).Jean-Marie Zimmermann, Michel Blanc, Pierre Mashoyan, ÉrickZimermann, Jean-Marc Grimaldi. Clairval Private HospitalCenter, Marseille, France.
The authors present a review of their experience withAdjustable Gastric Banding, commencing in July 1995, after tenyears of practicing both conventional VBG and laparoscopicbariatric surgery, from 1985 to 1995. From this experience, theyderive a different approach for the future. From July 1995through April 2001, 1410 patients underwent surgery. Theseries meets the same criteria as the series in the literature:mean age 41 years (17- 65), mean BMI 43 kg/m? (35-80), meanweight 114 kg (83- 230), mean excess weight 43 kg, 85%women to 15% men, and 174 patients with a BMI greater than50 (14.1%).The materials used were 1090 LAGB (original tech-nique), 105 SAGB, 103 LAGB (pars flaccida technique), 123LAGB (11 cm.), 2 PIER systems. A total of 1423 gastric bandswere placed, due to removal and replacement of materials (15cases).
The results are expressed as a percentage of excess weight
lost: 50% after one year, stable through five years. Out of 1326patients who underwent surgery from July 1995 throughDecember 2000, results for only 1106 patients were used (85%women to 15% men, with a mean age of 41 years, and a meanBMI of 43). The results were encouraging from the perspectiveof weight loss expressed as a percentage of excess weight:45% after one year for 950 patients followed out of 1106; 43%after two years for 371 patients followed out of 742; 41% afterthree years for 145 patients followed out of 355; 48% after fouryears for 30 patients followed out of 101. The efficacy of GastricBanding seems more limited when the initial BMI is greater than50 (approximately 40% after one year, sustained for fouryears?).
Of all complications, two types seem the most serious: slip-page, 11% in our series, and migration, 0.3% in our series.Thefrequency of each of these complications seems to vary,depending on the type of band and the placement technique.Slippage is most frequent with the LAGB (up to 18%). We had129 cases of slippage out of 1090 surgical cases using theLAGB with the original technique (11%), seven of which under-went two repositioning procedures. All of these cases requiredlaparoscopic reoperation for repositioning the band, including allcases where the band was opened, not opened or replaced.This complication rate had no specific peak during the post-sur-gical period. There were 0.3% to 5% of such cases of slippageeach month, commencing in the first month post-surgery.
Migration is most frequent with the SAGB (up to 4.6%). Thisband has a balloon that rolls up in the event of “overinflation,”and allows the sharp edge of the band to come in contact withthe visceral layer, creating a point of friction, whence the possi-bility of erosion. We had three cases of delayed intragastricmigration (0.3%) through the anterior stomach wall. Theseoccurred with the first generation LAGB, from month 36 throughmonth 40, which eliminates any etiology related to dissectiontoo close to the posterior stomach wall.
With all other systems – 10.0 LAGB in the pars flaccida posi-tion (103 surgical patients), 11.0 LAGB with a wider balloon inthe pars flaccida position (123 surgical patients), SAGB also inthe pars flaccida position (105 surgical patients), PIER system(2 surgical patients), i.e., a total of 333 patients – we have hadno more slippage for one year, while with the LAGB using theoriginal technique, 27 removals were required due to slippage.
By comparing the different materials, their design and posi-tioning, the authors endeavor to suggest an explanation forthese complications.The mortality from this series was 0.7 perthousand, which makes this method of Gastric Banding theleast aggressive of all the recommended surgical techniques,especially if we take into account the risk-to-benefit ratio.
P54.BARIATRIC SURGERY COMPLICATIONS WITHADJUSTABLE LAPAROSCOPIC GASTRIC SYSTEM (LAPBAND). PREVENTION AND TREATMENT.Carlos Alberto Casalnuovo, Ezequiel Ochoa de Eguileor,Gustavo Parrilla, Eduardo Liljesthröm. Hospital de Clínicas,University of Buenos Aires, and Private Practice (CCO-Centrode Cirugía de la Obesidad), Buenos Aires, Argentina
Background: Laparoscopic adjustable gastric banding is con-sidered as a good and safe operation and is an attractive alter-native for patients who can benefit from a simple restrictivebariatric procedure.Nevertheless, complications may occur, and therefore standarsand strategies in the prevention and treatment of complicationsshould be defined.
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Methods: From January 1998 - January 2001 we placedLaparoscopically 150 adjustable gastric banding (Lap Band).The mean preop. BMI was 52.8 (35-89.3). The 56% had a BMI=/>50 (SO, SSO, TO) and 12% =/> 66 (triple obese) The complications found were analyzed and divided intointraop, early and late postop.
Results: During the operation, 4 (2.7%) bleeding trocarwounds, were easily treated with electrocautery or suture;1 proximal tube fracture was repair with metal connector; 1abdominal esophageal tear (4cm) for inopportune calibratingballoon inflated in wrong place by the anesthesiologist, could besutured laparoscopically with good result. In the early stage ofthe postop.: 1 hemopenritoneum needed a relaparoscopy at48hs. for a slight bleeding trocar wounds; 1 patient with acutepulmonary edema, needed artificial ventilatory support from thesurgery until 72hs.; 2 minimus biliary hipertension syndrome,one (cholecystectomy as simultaneous associate procedure forgallstone) have been resolved with ERCP one week later. Theother one, developed it at the end of the 1st month, have beena spontaneous resolution (biliary sludge); 4 (2.7%) port infection(7 – 15 days postop.). The 1st patient presented 2 recurrentabdominal wall abscess even after port removal (3m postop.),and 12 months after we decided ralaparoscopy far away fromseptic zone and turning away the tube with a segment added tothe opposite part of the abdomen wall. A early relaparoscopy (2-3m) with port removal was done to the 2nd and 3rd patients andin one of them a simultaneous new port was placed. The 4thpatients we give up the tube into the abdomen with end plug forprotrusion of it. Segment of the tube in the section area weretaken for culture with negative results, as negative endoscopiesin all patients for erosions.
As late complications we found 2 slippages (1.3%). Oneanterolateral, acute, 4 _ months after operation, with clinical andradiological diagnosis with the ring moving to inverted positionwas reduced by relaparoscopy under the band, and new line offixation sutures were used. The posterior slippage (perigastrictechnique in primary operation) was developed 12m postop., ini-tially controlled by band deflation, but the re-banding by rela-paroscopy in a higher level was carried out 4 months later. Onepatient with leakage from band-balloon was re-banding 3months postop by relaparoscopy. Another patient (0.7%) withgastric erosion, 9 months after operation, was debanding byrelaparoscopy. The total reoperation rate by relaparoscopy formajor complications, including 3 port infection, was 5.3% (8patients).There was no mortality.
Conclusions: Laparoscopic adjustable gastric banding seemsto be a safe and satisfactory procedure with a low rate of com-plications. _ It requires a very strict patient follow up and a goodselection. _ Most of the reoperations can be performed by rela-paroscopy. _ It is necessary, strict control of the trocar woundsbefore the operation end, to avoid contingent hemorrhages. _With “pars flacida” modification we decrease surgical time, amore simple dissection in superobese patients and higher andstable position of the band, avoiding posterior slippage. _ It isvery important exactly fixation of the stomach over the band toprevent anterior slippage. _ Always must be tested the balloonbefore placed the band, to recognize unexpected band defects._ It is not recommended to do a simultaneous cholecystectomyas associated procedure, except that the patient has syntomaticgallstones. _ A good alternative in port infection is an early turn-ing away the tube to an aseptic area with or without new portimplant. _ The recurrent infection of the port area may be fol-lowed by tube / band contamination that could be involved in the
etiology of band erosion / migration.
P55.CHANGED EATING BEHAVIOR PRODUCED BYCHRONIC BILATERAL VAGUS NERVE STIMULATION.M.S. Roslin, R. Reddy*, S. M. Parnis**, B. T. Barrett**. Lenox HillHospital, New York, NY, *Maimonides Medical Center, Brooklyn,NY, **Cyberonics, Inc, Houston, TX, USA
Background: Obesity is one of the most prevalent diseases inthe western world. However, treatment options remain less thanoptimal. Previous reports have suggested the importance of thevagal afferents in the transmission of satiety signals from the gutto the brain. The aim of this study was to determine whethervagus nerve stimulation (VNS‰) using the NCP® System(Cyberonics; Houston, Texas) could alter eating behavior andresult in weight loss in a canine model.
Methods: From September 1998 to March 2000, a total ofeleven studies were performed in a canine model. BipolarLeads were placed on the distal bifurcating vagal nerve trunksin the subdiaphragmatic (1/11) and in the supradiaphragmatic(10/11) position. In the supradiaphragmatic series, two studies(2/10) were performed using programmed stimulation parame-ters that delivered electrical signals 30 minutes before and dur-ing meal consumption time only (acute stimulation). Eight stud-ies (8/10) were conducted with the programmed stimulationparameters delivered in various duty cycles continually through-out the day (chronic stimulation).
Results: Eating behavior was significantly altered during thechronic stimulation studies, with increased consumption timesand reduced consumption amounts. No clinically significantchanges were seen in hematologic or biochemical blood pro-files. No pulmonary or cardiac problems were encountered inany animal during the study. Upper gastrointestinal endoscopystudies performed at the conclusion of the chronic studiesshowed no abnormalities in esophagus, stomach or duodenum.Compared with the normal vagus trunk of the dog, the vagusnerves of study animals showed no clinical gross or histopatho-logic changes.
Conclusions: During chronic stimulation, distal VNS can alterthe eating behavior of the dog.
P56.COMPARISON OF DIFFERENT TECHNIQUES OFLAPAROSCOPIC PLACEMENT OF ADJUSTABLE GASTRICBANDS.R. Weiner, D. Wagner, R. Blanco-Engert. MIC-ZentrumFrankfurt-Sachsenhausen, Frankfurt a.M., Germany
A randomized prospective study was constructed in order todetermine whether laparoscopic esophagogastric placement(EGP) is associated with lower incidence of postoperative SPand pouch dilation than after retrogastric placementRGP.Morbid obese patients presenting for LAGB were random-ized to undergo either an EGP (n=50) or a RGP (n= 51).Patients were blinded to which procedure had to be performed,and follow-up was obtained by a blinded independent investiga-tor. Standardized clinical and radiological controls were used toasses pouch enlargement and SP.Operating time was similar forthe two procedures (54,5 min for the EGP versus 58 min forRGP). There was no significant difference in postoperativeweight loss (34 kg after EGP versus 37 kg after RGP within 12month), esophagus dilation or postoperative quality of life.Therewas one postoperative SP and one pouch dilation in the RGPgroup versus no postoperative complication in the EGPgroup.Conclusions:The placement of LAP-BAND in EGP-tech-nique is safe and followed by a lower frequency of postoperative
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complications, than in RGP-technique. Clear anatomical land-marks are a benefit to education and learning curve of LAGB.
P57.MINIMALLY INVASIVE REINTERVENTIONS TO TREATCOMPLICATIONS AFTER BARIATRIC SURGERY.F. Aigner, MD., H. Weiss, MD., H. Nehoda, MD., H. Bonatti, MD.Univ. Hospital of Surgery, Dep. of Gen. Surg., Innsbruck, Austria
Background: Bariatric operations are mostly performedlaparoscopically, but also by open surgery. Nevertheless most ofthe reoperations can be done also by laparoscopy.
Methods: Between 1.1.1996 and 31.3.2001 in 383 patientswith bariatric operations we had to operate on 79 complications.31 reinterventions were done in local anesthesia due to port-complications, 6 cases of intragastric bandmigration were man-aged gastroscopically and 39 laparoscopic reinterventions in 29patients were necessary due to different reasons.
Results: Only in 3 cases of gastric perforation the reinterven-tion has to be done by laparotomy. The most common laparo-scopic reoperation was to renew the band within one session in17 cases (leckage of the band in 9 cases, stoma narrowing withpouchdilatation due to too small banddiameter in 8 cases). All 6cases of late pouchdilatation could be corrected laparoscopi-cally without bandexchange, 6 times we removed the bandlaparoscopically on desire of the patients (4 cases with latedilatation.2 cases without complication ). We put in a new bandseveral month after removing the old one in 4 patients due to dif-ferent reasons (1 migration, 1 infection, 2 perforations), and 3times we had to recover an intraabdominal tubedislocation aftertuberupture. 2 patients with VGB recived an adjustable gastricband, one VGB was removed, all on laparoscopic way.
Conclusions: Most complications after bariatric surgery in ourseries could be managed by minimally invasive techniques suchas local, endoscopic or laparoscopic methodes,even when thefirst operation was done by laparotomy (6 cases). Only in threepatients (<1%) with gastric perforation we had to perform anopen operation.
P58.INCIDENCE OF SMOKING AND WEIGHT LOSS IN OURBARIATRIC POPULATION.Joseph F. Capella, MD., Rafael F. Capella, MD. HackensackUniversity Medical Center, Hackensack, New Jersey, USA
Background: An estimated 33% of the world’s populationsage 15 and above smoke regularly. Along with obesity, tobaccois one of the major world health problems. In this study we ana-lyzed the incidence of smoking and weight loss in our bariatricpopulation of 1060 patients that underwent Vertical-BandedGastroplasty-Gastric Bypass.
Methods: All patients undergoing this type of surgery com-pleted a questionnaire that encompassed smoking habits. Theywere divided in A=nonsmoker, B=less than half a pack, C=onepack daily and D=more than one pack daily. An overall inci-dence of smoking and percentage excess weight loss at threeyears were analyzed.
Results: The incidence of smoking in this group of patientswas less than the population in general. Only 17% of patientshave contact with tobacco and only 2.5% smoked more thanone package daily. Excess weight loss was superior in allgroups of smokers as compared to nonsmokers. A=73%,B=79%, C=79% and D=84%. Despite the small number ofsmokers, the results were statistically significant when Group Awas compared to group B (p>0.05) and D (0.03).
Conclusions: Fortunately, our bariatric patients appear tosmoke less than the general population. The miss blessing of
superior weight loss should be further analyzed considering thedevastating effects of smoking. Smoking probably should beused as a predictor of weight loss after bariatric surgery andshould also be taken in consideration in expressing weight lossresults, specially in countries where smoking is more prevalent.
P59.SOLID STATE BARIUM MEAL IN LAP-BANDSINSERTED WITH PARS FLACIDA TECHNIQUE.Marina S. Kurian, MD, and Mitchell S. Roslin, MD. Departmentof Surgery, Lenox Hill Hospital, New York, NY., USA
Background: Laparoscopic adjustable gastric banding hasbeen performed worldwide for several years. Conventional wis-dom states that the band creates a pouch and eating causesmechanical distension of the pouch with cessation of foodintake.To explore the mechanism of early weight loss in patientswho underwent band placement we performed solid-state bar-ium meals prior to any adjustment.
Methods: Four LAP-BAND patients underwent insertion of a9.5 sized LAP-BANDs using the Pars Facida technique. Bandswere not inflated. A barium meal (bagel soaked with barium)was performed under fluoroscopy 5 to 6 weeks post operatively.Mean weight loss at this point was 17 pounds with a range of9 to 24 pounds. Images were taken with solid ingestion untilsatiety or dysphagia was reported.
Results: With the band left uninflated, we saw no delay inpassage of solid material with satiety or dysphagia.
Conclusion: The absence of delay in passage of solid mater-ial indicates that gastric distension of a small pouch is not thecause of early weight loss in bands placed through the ParsFlacida technique. Instead, our data supports the hypothesisthat a proximally placed band inhibits receptive relaxation, andrapid food ingestion causes dysphagia. Consistent with this arereports that bands placed at the Pars Flacida require feweradjustments. Further investigation with additional patients, andcomparative studies with patients with more distally placedbands are necessary to understand how the Lap-Band changeseating behavior and how this varies with the location of theband.
P60.THE INFLUENCE OF GASTRIC BANDING ON PLASMA-AMINOXIDASE (PAO) - A POSSIBLE PROGNOSTIC FACTORIN OBESITY ASSOCIATED MORBIDITY.J. Klocker, B. Labeck, H. Nehoda, F. Aigner, A. Klingler, C.Ebenbichler, B. Föger, M. Lechleitner, H. Schwelberger, H.Weiss. Departments of General Surgery and Internal Medicine,University Hospital Innsbruck, Austria
Background: Increased activities of PAO, an enzyme convert-ing amines, have been implicated in the generation of endothe-lial damage through formation of cytotoxic reaction products.Weinvestigated if PAO activities are elevated in morbidly obesepatients which might contribute to the increased cardiovascularrisk and if adjustable gastric banding has impact on PAO activi-ties.
Methods: 45 patients underwent laparoscopic adjustable gas-tric banding (SAGB®, Obtech; median BMI 44.4 kg/m2). PAOactivities were determined (radiometric assay, normal value<450µU/m) pre- and postoperatively (245±105 days).32 healthyvolunteers (median BMI 23.3 kg/m2) served as controls. In addi-tion parameters of glucose and lipid metabolism were deter-mined and compared for subgroups of obese patients with nor-mal and impaired glucose metabolism and with diabetes.
Results: Morbidly obese patients showed significantly higherPAO activities than control subjects (431 versus 361µU/ml).
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After adjustable gastric banding significant reduction of BMI(p<0.001), fasting glucose levels (p<0.001), insulin (p<0.001),C-peptide (p<0.001), lipids (p<0.05) and PAO activity(371µU/ml, p<0.001) could be observed.PAO activities were notcorrelated with any clinical or metabolic parameter in obesepatients pre- or postoperatively.
Conclusion: Elevated PAO activities are found in morbidlyobese patients as an independent risk factor for obesity-relatedmorbidity. Adjustable gastric banding resolves impaired PAOactivities and improves the metabolic vascular risk profile.
P61.OUR CHANGING APPROACH TO THE PROPHYLAXISOF VENOUS THROMBOEMBOLISM IN BARIATRICSURGERY.Maria Laura Cossu, Enrico Fais, Matteo Ruggiu, ClaudioSparta, Franca Cossu, Giuseppe Noya. Department ofEmergency Surgery, University of Sassari, Italy.
Background: Morbidly obese patients undergoing bariatricsurgery have commonly been considered to be at high risk ofdeveloping perioperative venous thromboembolism. Due to itsclinical silent nature , primary prevention is the key to reducingmorbidity and mortality.
Method: Between February 1995 until February 2001, 144obese patients underwent bariatric surgery: In 134 patients(mean preoperative weight and BMI: 135.28 Kg- 51) we per-formed biliopancreatic diversion. 43 cases (32.8%) had associ-ated diabetes type 2 and 16 cases (12.2 %) had IGT. In 74cases (56.4%) serious alterations of lipidic metabolism werepresent. In 10 patients ( mean preoperative weight and BMI:120.9Kg - 41.22) we performed VBG. Two of these patients(20%) had associated diabetes type 2 was associated and in 3had a slight hypercholesterolemia.At beginning of our experi-ence, in the first 65 cases, during the operation a dose ofheparin was administered endovenously (one shot of 2500-3000 Ul), immediately after anesthetization, as a safeguardagainst thromboembolism.The patient’s lower limbs were ban-daged and early ambulation was resumed in the first six hoursafter the operation. In the later period of our experience, (79cases), we changed the prophylaxis and in association withcompression stoking and early ambulation, we began to admin-ister low- dose sc heparin.The dosage (min 20.000 UI /die max35.000 UI /die divided in two administrations) was usually stabi-lized by testing the coagulation time and coagulation factorsevery day so to achieve a good anticoagulation.This treatmentusually started 4-5 days before operation and continued untildischarge (7-8 days after operation) . Low doses sc heparin(usually 5000-7500 UI x2/die) were administered after dis-charge for 7-10 days.
Result: In the first group of patient we observed 2 cases (3%)of acute pulmonary embolism on the 1th -2nd postoperativedays which was the immediate cause of death. In the secondgroup 1 case (1.2%) of non- fatal pulmonary embolism occurredon the 15th postoperative day : a urokinase injection in the mainpulmonary artery led the thrombosis resolution.
Conclusion: It is widely accepted that morbidly obesepatients are at high risk of developing perioperative throboem-bolism and the majority routinely undergo prophylaxis.There isno clear consensus in the literature regarding the optimumapproach to minimize this preventable phenomenon.Our expe-rience suggests that a "personalized heparin prophylaxis "before, during and after bariatric surgery could be the key toreduce morbidity and mortality.
P62.HEMODINAMIC AND CARDIAC FUNCTIONALIMPROVEMENTS AFTER SURGICAL TREATMENT OFSEVERE OBESITY.F. Mittempergher, D. Moneghini, B. Salerni, S. Nodari*, A.Madureri*, L. Dei Cas*. Chair of General Surgery and * Chair ofCardiology, University of Brescia, Italy
It is well known that alterations in the left ventricular (LV) func-tion occur in patients with severe obesity. Heamodinamic, meta-bolic, hormonal and neurovegetative changes may recover afterweight loss. We evaluated the haemodinamic and functionalchanges induced by weight loss after surgical treatment (bil-iopancreatic diversion, vertical gastroplasty) on patients withsevere obesity (body mass index, BMI>35). Fourthy patients (30females, 10 males), aged 41 ± 9 years (range 21-60), BMI 45 ±7 (range 36-72), weight 135 ± 28 Kg, were evaluated before andafter 30% weight loss caused by surgical therapy. We examinedthe changes in blood pressure and heart rate, the electrocar-diogram (electric axis, signs of LV hypertrophy, atrio-ventricularconduction and repolarization), Holter monitoring (maximal-min-imal-mean heart rate, ventricular and supraventricular ectopicbeats), and the echocardiogram (LV volumes and diameters,parietal thickness, fractional shortening, ejection fraction, andE/A ratio).
At baseline 8 patients were affected by hypertension on phar-macological treatment.The electrocardiogram showed left axialdeviation in 85% of the patients and signs of left ventricularhypertrophy in 35%. The echocardiogram showed normal LVdiameters, volumes, fractional shortening and ejection in all thepatients. LV hypertrophy was present in 18 patients and allshowed an abnormal filling pattern with an E/A value of 0.8 ± 1.Holter monitoring showed supraventricular and ventricularectopic beats of moderate frequency in 8 and 11 patients,respectively (0.4 ± 0.7 VPB/24 hours and 0.8 ± 1.2 SVPB/24hours).
Surgical therapy caused a reduction in BMI from 45 ± 8 to 40± 8 and in body weight from 135 ± 28 Kg to 105 ± 20 Kg(p<0.001 in both cases) with a concomitant reduction in heartrate (from 78 ± 11 to 65 ± 12 b/min, p<0.05), diastolic bloodpressure (from 79 ± 10 to 72 ± 6 mmHg, p<0.05) and meanheart rate at Holter monitoring (from 80 ± 9 to 66 ± 10 b/min,p<0.001).The echocardiogram showed a significant reduction inLV end-systolic diameter from 31 ± 3 to 27 ± 4 mm (p<0.05), LVend-systolic volume from 36 ± 10 to 28 ± 8 ml (p<0.05), inter-ventricular septal wall thickness from 11 ± 2 to 9 ± 2 mm(p<0.05) and posterior wall thickness from 11 ± 2 to 9 ± 1 mm(p<0.05) with an increase E/A ratio from 0.8 ± 1 to 1.4 ± 2(p<0.05).
In conclusion, severe obese patients treated by surgery canobtain, at 30% of weight loss, a significant reduction in heartrate, diastolic blood pressure, LV end-systolic diameters andvolumes, and wall thickness with an improvement of the LV fill-ing pattern and overall function.
P63.LAPAROSCOPIC GASTRIC BANDING IN THEELDERLY.H. Nehoda, MD; K. Hourmont, MD; T. Sauper, MD; R. Mittermair,MD; M. Lanthaler,MD;F. Aigner, MD; H. Weiss, MD. Departmentof General Surgery, University Hospital of Innsbruck, Austria
Hypothesis: Elderly patients experience the same benefitsfrom a laparoscopic gastric banding operation (LGB) as doyounger patients.
Design: A case series of 320 morbidly obese and superobesepatients who underwent laparoscopic gastric banding (LGB)
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within a 46-month period.Patients: A consecutive sample of 320 patients who met the
criteria for a bariatric procedure and were 18 years or older.Patients were divided into the following two groups: youngerpatients (between 18 and 49 years old) and elderly patients (50years or older).
Intervention: Laparoscopic gastric banding (LGB) with theSwedish adjustable gastric band (SAGB, Obtech Switzerland).
Main Outcome Measures: Clinicopathologic features includ-ing weight loss, complications, length of hospital stay, operativetimes of these patients were reviewed retrospectively and a mul-tivariate analysis carried out.
Results: Of 320 patients, we identified 68 (21.5%) elderlypatients. The mean postoperative follow-up period was 12months (range: 6-28). The average preoperative weight was127.8kg (BMI 44.29 kg/m2). The average total weight-loss was4.3 kg per month, reaching an average total of 28 kg after oneyear. The excess weight loss (EWL) after 12 months was 68%.Complications requiring reoperation occurred in 10.3% (vs.7.3% in the younger group). Ninety-seven percent of thepatients reported an improvement in their co-morbid conditions.
Conclusions: Elderly patients receive the same benefits fromLGB as younger patients, although they have a slightly higherpostoperative complication rate (3.0%). Presently, our upperage limit is 70 years.
P64.ROUTINE CHOLECYSTECTOMY CONCOMITENT WITHBARIATRIC SURGERY: IS IT NEEDED?Papavramidis Spiros, Sapalidis Konstantinos, DeligiannidisNikolaos, Papavasiliou Ilias, Gamvros Orestis. 3rd Surg. Dept.AHEPA Hosp. Aristotelian University of Thessaloniki, Greece
Background: Routine cholecystectomy concomitent withbariatric surgery is controversial. This study documents moreclearly the gallbladder disease of morbidly obese patients whounderwent bariatric surgery (vertical gastroplasty).
Methods: A total of 220 consecutive morbidly obese patients(BMI > 40Kg/m2), who were treated by vertical gastroplastybetween 1990 and 1999, were included in the study. Patientswere divided in two groups. Group A consisted by 120 consec-utive patients (1990-1994), 29 male and 91 female with a meanBMI=53±10 Kg/m2, who were managed by routine cholecystec-tomy concomitent with vertical gastroplasty. Group B was com-posed by 100 consecutive patients (1995-1999), 38 male and62 female with a mean BMI=52,3±10 who underwent verticalgastroplasty without routine cholecystectomy.
Results: Ten patients (8,3%) of group A, and 2 (2%) of groupB had undergone cholecystectomy before bariatric surgery.Ninety seven percent of the removed gallbladders of group Ahad gross or histologic abnormalities including cholelithiasis22,5% (27 patients), cholesterolosis 21,6% (26 patients), sludge10,8% (13 patients) and chronic cholecystitis only 41,6% (50patients). Twenty-five patients of group B (25%) underwentcholecystectomy because of preoperative and intraoperativediagnosis of cholelithiasis and additional one (1%) because ofadenomyosis. From the 72 patients of group B with an intactgallbladder, in 26 patients (36%) a symptomatic cholelithiasiswas developed within two years after bariatric surgery, and alaparoscopic cholecystectomy was performed in all of them,which was reverted in open in 6 cases (23%). In group B theBMI of the patients with cholelithiasis was significantly greaterthan that of patients with cholecystitis. In group B the patientswho developed cholelithiasis after gastroplasty had not signifi-cantly greater BMI than those without disease.
Conclusions: The high incidence of gallbladder disease inmorbidly obese patients in general, in combination with the highincidence of cholelithiasis after bariatric surgery and the diffi-culties in the laparoscopic management, lead us to concludethat cholecystectomy should be performed in all morbidly obesepatients concomitently with bariatric surgery.
P65.IMPROVEMENT IN METABOLIC CO-MORBIDITIESFOLLOWING WEIGHT LOSS FROM GASTRIC BYPASSSURGERY.Richard S Stubbs. Wakefield Gastroenterology Centre,Wellington, NZ
Background: Clinical observation reveals a close associationbetween morbid obesity and a variety of serious medical condi-tions. This report describes the changes observed in some ofthe co-morbid conditions commonly associated with morbidobesity following the weight loss achieved by silastic ring gastricbypass (SRGB).
Methods: Between 1990 and 2000, 259 morbidly obesepatients (60 M, 199 F) aged between 15 and 68 years under-went SRGB. Initial and follow-up data was recorded prospec-tively on a computerised database, with minor subsequent addi-tions being achieved by phone call or questionnaire.
Results: Median pre-operative BMI of the group was 44.5 (33-78). Patients were followed for a minimum of 2 years, at whichtime median BMI was 28 (20-52). Prior to surgery we notedhypertension in 91 (35%) patients, Type 2 diabetes in 37 (14%),abnormal glucose tolerance in 48 (19%), dyslipidaemia in 139(54%) and hepatic steatosis in 232 (90%). Following surgery nopatient with prior impaired glucose tolerance has become dia-betic, and 33 of those with diabetes are no longer diabetic.There has been resolution of hypertension in 51 and improve-ment in a further 27. Hypercholesterolaemia which was presentin 137, normalised in 50 and improved in a further 43.Hypertriglyceridaemia which was present in 96, normalised in59 and improved in another 6. Total cholesterol/HDL chol whichwas elevated in 139, normalised in 76 and improved in a further22. Hepatic steatosis improved in 21/28 patients in whom repeatliver biopsies were available.
Conclusions: Our findings indicate substantial weight loss isaccomplished by gastric bypass surgery with accompanyingmajor reductions in the associated metabolic co-morbidities.
P66.NORMAL BODY WEIGHT IS THERE A REALISTICCHANCE AFTER BARIATRIC SURGERY?B. Husemann, Th. Sonnenberg. Dominikus-Krankenhaus P.O.290151, D-40528 Dusseldorf/ Germany
To calculate the questions, whether morbid obese patientscan reach and keep normal body weight after bariatric surgeryor not is very important not only for the patients but also for lifeinsurances and social services. We have analysed our ownpatients 60 month after VBG (n = 91) and lap band (n = 37).Theprae-op body weight demonstrates the morbid obesity with aBMI of 49,1 respectively 47,2 kg/m2. After five years 46,2% or43% of all operated patients have a body weight below 30 kg/m2
and 17% respectively 21% under 25 kg/m2 or normal weight. However, 29% or 26% are above a BMIof 35 kg/m2. The reasons are different: One third of thesepatients are sweet eaters and one third shows abnormal eatingbehaviour with sweet, high caloric soft drinks. By 7 patientsoesophageal pooling seems to be the reason for the insufficientweight loss. Therefore, bariatric surgery alone would be insuffi-cient, there is necessary a training for eating, chewing and
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cooking, too. We suggest a prae-operative psychosomaticcheck up, to evaluate the eating behaviour and to adapt the sur-gical procedure.
P67.PATIENT CHARACTERISTICS INFULENCING WEIGHTLOSS FOLLOWING LASGB-OPERATION.Ralph Peterli, Yael Anner, Peter Tondelli. Surgical Clinic,St.Claraspital Basel, Switzerland
Background: There is a controversy whether the laparoscopicadjustable gastric banding operation (LASGB) as a purelyrestrictive bariatric procedure is indicated in some patients(sweets eaters, superobesity).We investigated the influence ofpreoperative patient parameters (BMI, gender, eating behavioretc.) on weight loss by performing LASGB as the primary inter-vention in all morbidly obese patients.
Methods: Between 12/96 and 5/00 LASGB was performed in164 patients (84% female) with an average body weight of 127(91-250) kg, BMI of 45 (33-75) kg/m2, aged 40 (17-64) years.All patients were prospectively evaluated and followed using astandard protocol after a mean of 18 (4-48) months. All patientsremained in the study including such with pregnancy during thepostoperative course, re-operations or failure.
Results: The average excessive weight loss was in the 1styear 46% (n=120), in the 2nd 50% (n=57), in the 3rd 57%(n=16) and in the 4th year 43% (n=1). A better weight loss couldbe observed in women, in patients without the feeling of satura-tion preoperatively, with successful weight loss under conserva-tive treatment (more than 20 kg), in patients without regularintake of sweets and without snacking. Some sweets eatersstop eating sweets after LASGB others develop this eating dis-order de novo. Patients with a preoperative BMI > 50 kg/m2showed less weight loss initially but after 3 years no such differ-ence could be found. No correlation could be demonstratedbetween weight loss and education, patient number and bigeaters.
Conclusion: Some patients (sweets eaters, male gender)loose less weight after LASGB but the prognosis cannot bemade in the individual case. Superobesity does not seem to bea contraindication for LASGB.
P68.POSTOPERATIVE THROMBOEMBOLIC COMPLICA-TIONS AFTER OBESITY SURGERY.A Westling MD, Ph D & S Gustavsson Assoc prof. Departmentof Surgery University Hospital Uppsala, Sweden
Background: Obesity is often claimed to be a risk factor forpostoperative thromboembolic complications. The incidence ofpostoperative deep venous thrombosis (DVT) after obesitysurgery is incompletely known.
Methods: During 1996-2000 we have performed 285 Roux-en-Y gastric bypass procedures (RYGBP). In 94 patients(median BMI 38 kg/m2) RYGBP was a revisional procedure afterprevious failures with VBG and banding procedures. 191patients (BMI 44 kg/m2) had not undergone obesity surgerybefore. 44 procedures were done laparoscopically and 30 withHand-assisted laparoscopic technique. All patients hadobtained enoxaparin 20 mg daily or 500 ml dextran in a singledose as routine thrombosis prophylaxis during the hospital stay.During Dec 1996-april 1998 116 of these patients were consec-utively investigated with Duplex scanning pre and postopera-tively to investigate the presence of deep venous thrombosis ordeep venous insufficiency.
Results: During this five year period with 285 RYGBP proce-dures there were 2 (0.7%) patients with symptomatic DVT diag-
nosed with phlebography several weeks after discharge and 1(0.35%) patient was presented 3 weeks postoperatively with aangiographically diagnosed minor pulmonary embolism.Furtherinvestigation proved an unknown activated protein C resistance.One (0.35%) patient died 4 days postoperatively and the post-mortem examination revealed a pulmonary embolism as a pos-sible cause of death. This patient had a Prader Willi condition.The patients (116/285) participating in Duplex scanning had nosymptomatic thromboses. However, the scanning revealed twothromboses in one of the calf veins in two patients (0.7%) andone patient (0.35%) with a thrombus in the long saphenousvein.These 3 patients were treated with 40 mg enoxaparin dailyand at repeated scanning after one week the thrombi wereresolved.
Conclusion: Tromboembolic complications after RYGBP isuncommon in this study;1.4% DVT including asymptomatic calfthrombosis and 0.7% PE including one fatal.
Biliopancreatic diversion is a very effective procedure andhas been successfully used as one of many surgical treatmentsto achieve significant long term weight loss.This idea lead us toperform bilipancreatic diversion by using a mini-invasiveapproach. To reduce laparoscopic Scopinaro difficulty we avoidthe gastrectomy. Our procedure consists of a proximal gastrictransection with a long Roux-en-Y reconstruction (Video pre-sentation).
Patient in the supine position with head-up tilt with the sur-geon operating on the left and the assistant between the legs ofthe patient.The main monitor should go at the head of the table.The laparoscope is first placed through an umbilical port (10mm) and initial inspection of the peritoneal cavity performed.Wefavors a 30-degree forward-oblique viewing laparoscope Twoadditional left upper quadrant trocars (12 mm) and a right upperquadrant trocar (12 mm) are placed under direct vision.In order to create the Roux-limb, the jejunum is divided 200 cmbeyond the caecum by using an Endo GIA, 45 mm long with 3.5mm staples. In addition the mesentery is divided with a har-monic scalpel. The Roux-limb is measured from caecum to 50cm in ileon length. An side-to-side anastomosis between theproximal jejunum and the Roux-limb is created by firing a EndoGIA II staplers. The enterotomy is closed using a continuoussuture.
A retrogastric-retrocolic tunnel is performed in the mesocolonanterior and lateral to the ligament of Treitz.The stomach is sized to a small pouch. The site of incision isdetermined at the greater curvature and performed a retrogas-tric tunel. Select the proximal transection site, the Endo GIAstapler, 45 mm long with 3,5 mm staples is then fired threetimes as shown horizontaly.
The Roux-limb is now advanced trough the mesocolic win-dow (retrocolic) near the transected stomach when is fixed withinterrupted sutures. Following an enterotomy an anastomosisbetween the gastric pouch and the Roux-limb is created by fir-ing a Endo GIA II. The enterotomy is closed using a continuoussuture.
P70.QUALITY OF LIFE IS IMPROVING AFTER LAP-BANDGASTRIC BANDING FOR MORBID OBESITY.Saida Bedda, Jean-Marc Chevallier, Franck Zinzindohoue,Richard Douard, Jean-Louis Berta, Jean-Jacques Altman, Paul-
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Henri Cugnenc. Departments of Surgery and Nutrition. HôpitalEuropéen Georges Pompidou, 20-40 rue Leblanc 75908 PARIScedex 15, France
Background: Improvement in quality of life is the principal aimof surgery against morbid obesity. Excess weight loss (E.W.L.)is a quantitative purpose, but clearance of comorbidities andimprovement of quality of life are at least as important. TheBariatric Analysis and Reporting Outcome System method(BAROS), introduced by Oria and Moorehead in 1997, was pro-posed to standardize the results of bariatric procedures.Weused this method to evaluate our results on an experience offour years.
Method:This system use a point scale to evaluate in onepage record three important fields:weight loss, improprement ofmedical conditions and quality of life after surgery. Colouredillustrations are used to evaluate five areas: self esteem, physi-cal activity, social life, working conditions and sexuel satisfac-tion. Complications and re-operations also result in substractionof points. The final scoring table classifies five groups depend-ing on the total points :failure 1point or less, fair > 1 to 3 points,good >3 to 5 points, very good >5 to 7 points and excellentresult > 7 to 9 points. From april 1997 to january 2000, among300 patients 140 , who underwent lap-band surgery, were eval-uated with BAROS, 128 women (91%) and 12 men (9%). Themean age was 41 yrs (22-68), the mean body weight was 117Kg (85-195) and the mean body mass index (BMI) was 43Kg/m2 (31-61). The mean follow-up was 14 months (6-31).
Results:BMI decreased from 43 Kg/m2 to 38 after 6 months(n=48), to 34 after 12 months (n=38), to 32 after 18 months(n=32) and to 31 after 24 months (n=11). EWL increased to 41%at 6 months, 44% at 12 months, 54% at 18 months and 24months. BAROS score was 3.64 at 6 months, 3.79 at 12months, 4.38 at 18 months and 5.20 at 24 months. According toBAROS, the global failure rate was 6%(n=8), fair results 18%(n=25), good results in 49% (n=68), very good results in 24%(n=34) and excellent results in 3% (n=5).The BAROS score andthe quality of life (auto-evaluation) were correelated significantlyto the excess weight loss (p> 0,01).
Conclusion: The quality of life evaluated by the BAROS sys-tem after lap-band surgery was good, very good or excellent in107 /140 of cases (76%). The BAROS and quality of lifeimproved with time significantly.
P71.OUR BARIATRIC SURGERY EXPERIENCE WITHADJUSTABLE GASTRIC BANDING.Bressani Doldi Santo, Micheletto G., Perrini M., Lattuada E.,Zappa M.A., Fioravanti M. Cattedra di Chirurgia Generale
dell’Università degli Studi di Milano - Istituto ClinicoSant’Ambrogio (Direttore: Prof. S.B.Doldi) ; Centro per laFarcomacoterapia delle Malattie Nutrizionali e Metaboliche “E.Genovese e R. Klinger”, Milan, Italy
Background: Since 1993 we have operated on 325 morbidlyobese patients with adjustable gastric banding according toKuzmak : 43 with open technique, 262 with laparoscopic tech-nique(Lap-band®). Rate of conversion to open laparotomy was7,6% (20 patients).The patients were examined by a multidisci-plinary team.The indications and contraindications we have fol-lowed were the same adopted in NIH conference (1991).
Methods: Our series includes: 325 patients (63 Male/262Female); mean age 37,5 y (18–67); preoperative mean weightKg 118,8 ± 24,7 (85-218); mean BMI 43 ± 6,8 (35-71); mean fol-low-up is 6 years.The patients in open surgery were: 24 in pre-laparoscopic era; 12 conversions from jejuno-ileal bypass; 1conversion from bilio-intestinal bypass;3 conversions from bilio-pancreatic diversion; 3 from silastic ring vertical gastroplasty.
Results: The mean weight loss after two years is 30.2% of theinitial mean weight, with the reduction of the excess weight of62,5% and in BMI of 29,5%.The main early complications were:gastric perforation (2,4%), half repaired in laparoscopy; hemor-rhage from short vessels (1 patient) repaired in laparotomy;band slippage(2 patients), one treated by removing the bandand the other by replacement in laparoscopy. All these compli-cations occurred at the beginning of our experience.The majorlate complications were: migration of the adjustable gastricbanding (0,9%); dilatation of the proximal gastric pouch (9,2%),50% treated by medical care and the other by surgery (removalor replacement of the gastric banding or conversion in bilio-intestinal bypass).Those medically treated were early identifiedby a water soluble upper gastric contrast study : our more than2000 contrast studies showed that the gastric pouch dilatationcan be facilitated by an oesophago-banding angle includedbetween 210 and 150°. Other minor late complications wereleak or infection of the device (2,4%).
Conclusion: The adjustable gastric banding and specificallythe Lap-band is the first choice surgical treatment in the major-ity of the morbidly obese patients. Lap-band is effective, adapt-able and economically advantageous. These good results arepossible only in bariatric specialized centers and following thissuggestions: virtual proximal gastric pouch (15 ml); embeddingthe banding with non absorbable stitches; diligent follow-up,above all to early recognize gastric pouch dilatation by x-raystudies; adherence of the patient to definitively mutation of thealimentary habit.
