body mass index (BMI), endoscopic and histologic findings. Results The medical records of 64 consecutive patients who underwent screening endoscopy for bariatric surgery evaluation from 07/2008 - 11/2009 were reviewed. There were 51 women with a mean age of 52 years (range 25-72 years) and mean BMI of 44 (range 30-63). Erosive esophagitis was detected in 6 patients (2 each, grades A, B and D). Barrett's esophagus was found in 9 patients (5 female; 6 short segments <3cm; 2 with low grade dysplasia (LGD)). Eosinophilic esophagitis and H. pylori gastritis were found in 1 and 2 patients, respectively. Esophageal varices were found in 3 patients, one treated with band ligation. GAVE was noted in 1 patient. Six patients had prior bariatric surgery (3 gastric banding, 3 gastric bypass). Duodenal villous atrophy consistent with sprue was found in 1 patient. Conclusion Overall, endoscopic pathology was found in 22 of 64 patients in this study (34%) including Barrett's esophagus or erosive esophagitis in 15/64 patients (23%) Abnormalities are common in relatively young patients undergoing screening endoscopy as part of their bariatric surgery evaluation. These findings support the Societal guidelines recommending screening endoscopy prior to bariatric surgery.
Small Intestinal Bacterial Overgrowth in Patients With Morbid Obesity Before and After Bariatric Surgery Jean-Marc Sabate, Benoit Coffin, Severine Ledoux, Muriel Coupaye, Benjamin Castel, Simon Msika, Pauline Jouet Background and aims: Roux-en-Y gastric bypass technique (RYGBP) by inducing bacterial stasis could promote small intestinal bacterial overgrowth (SIBO). In a previous study performed in 146 patients with morbid obesity (1) we found an increase in the prevalence of SIBO compared to healthy subjects 17.1% vs.2.5% (p=0.03). The aim of this study was to evaluate prospectively the prevalence of SIBO in a larger population of patients with morbid obesity, before and after bariatric surgery and its potential effect on vitamin deficiencies after surgery. Patients and methods: from October 2001 to July 2009, a glucose hydrogen (H2) breath test (BT, positive if fasting breath H2 concentration > 20 ppm and or increase > 10 ppm over baseline within the first 2 hours) was proposed to all obese patients referred for bariatric surgery (BMI > 40 kg/m 2 or > 35 in association with comorbidities) before and after bariatric surgery to assess the presence of SIBO. Vitamin levels (B12, B1, PP) were measured while vitamin supplementation was systematically prescribed after RYGBP. Results(mean ± SE, median (IQR) : 378 patients (336 women (88.9%), 39.6± 11.7 yrs, BMI : 45.7±6.3 kg/m 2 ) were included : 357 patients had a preoperative BT that was positive in 55 cases (15.4%), negative in 290 cases (81,2%) and doubtful or uninterpretable in 12 cases (3.4%). Twenty patients had BT after gastric banding [time since surgery 36 months (26-47), weight loss 22.9±14.1 kg] that was negative in 18 cases (90%) and positive in 2 cases (10%) (p = NS compared with preoperative situation). Sixty-five patients had a BT after RYGBP [time since surgery 9.2 months (6.8-23), weight loss 34.4± 11.5 kg] that was negative in 39 cases (60%) and positive in 26 cases (40%) (p<0.001 compared with preoperative situation). After RYGBP the percentage of patients with or without vitamin deficiencies was not different in patients with positive or negative BT (p = NS). Conclusion: in this study with a large number of patients, we confirm the presence of SIBO in 15% of patients with morbid obesity. After gastric banding, there is no increase in this prevalence while after RYGBP it increases to 40% of patients. In patients with systematic vitamin supplementation, a positive BT is not associated with an increase in the frequency of vitamin deficiencies. (1) Sabate et al. Obes Surg 2008 ; 18:371-377
M1361 Can Band Fill Volume Predict Gastric Band Stoma Size? John O'Dea, Robert G. Snow Introduction It has been previously demonstrated that the stoma created by a gastric band can be directly measured using a standardized technique, EndoFLIP (Crospon, Ireland). We sought to determine if the band fill-volume versus stoma size relationship changes between the time of surgery and at more than one year after surgery. Methods and Procedures Stomasize measurements were taken on 12 (12F) patients who were having a Model APS gastric band (Allergan Inc. Irvine, CA) implanted. The mean patient age was 43 years (range 2567 years). The mean patient weight was 235 lb (range 149-289 lb) with a mean BMI of 38.7 (range 29.2-50.2). Stoma-size measurements were also taken on 10 (7F) patients who had been fitted with the same type of gastric band at least one year previously. The mean time since surgery was 14.9 months (range 13-22 months). The mean patient age of this latter group was 41 years (range 20-62 years). The mean patient weight was 201 lb (range 172-242 lb) with a mean BMI of 31.4 (range 26.9-34.8). Previous work by the authors has suggested that titrating to a band stoma diameter in the region of 6.5 to 7mm, using 30mL inflation in the EndoFLIP balloon catheter, may place patients in the Green-Zone. The bandvolume required to achieve a 7mm stoma size was measured and compared for both groups. A model EF-325 catheter was used which has an 8cm long image field. It was deployed transorally to the band stoma. The EndoFLIP system was used to inflate the balloon catheter with 30mL of a calibrated diluted saline solution. As the band was filled, the stoma size could be measured directly from the EndoFLIP system screen. Results The band fill-volumes required to achieve a 7mm stoma size at surgery and after a year post surgery were measured to be (mean ± SD) 2.4 ± 1.0 ml and 6.6 ± 2.3 ml respectively, and were found to be significantly different (p<0.0001). The effect of peri-gastric fat elimination over time is evident as witnessed by the significantly greater band fill-volume required in the postsurgical patient group. Conclusion The variability of band fill-volume required for a given stoma size, both at surgery and particularly one year after surgery provides further evidence that band fill-volume provides little meaningful information as to what stoma size is being created. One reason for this is that any volume infused into the band, before the band is pressing snugly on the stomach wall, does not cause the stoma size to change. Further studies are underway to assess if making band adjustments, using stoma diameter measurements to guide such adjustments, impacts on number of adjustments and %EWL in the first year after surgery.
M1359 Restore: Randomized Evaluation of Endoscopic Suturing Transorally for Anastomotic Outlet Reduction: A Double-Blind, Sham-Controlled Multicenter Study for Treatment of Inadequate Weight Loss or Weight Regain Following Roux-en-Y Gastric Bypass Christopher C. Thompson, Mitchell S. Roslin, Bipan Chand, Yang K. Chen, Daniel C. DeMarco, Larry S. Miller, Michael Schweitzer, Richard I. Rothstein, David B. Lautz, Michele B. Ryan, Stacy A. Brethauer, Philip R. Schauer, Mack C. Mitchell, Anthony A. Starpoli, Gregory B. Haber, Marc F. Catalano, Steven A. Edmundowicz, Annette Fagnant, Lee M. Kaplan Background: Dilated gastrojejunostomy (DGJ) is one mechanism associated with failed Roux-en-Y gastric bypass (RYGB); however, revisional surgery is not generally performed due to the high rate of perioperative morbidity. The aim of this study was to prospectively evaluate 6-month weight loss following DGJ reduction (DGJR) via endoluminal suturing compared with sham endoscopy. Methods: With FDA/IRB approval, 77 subjects with BMI of 30-50 kg/m2 ≥6 months post-RYGB with inadequate weight loss and/or weight regain and GJ diameter > 2 cm were randomly assigned (2:1) to DGJR or sham control. All procedures were performed under general anesthesia. DGJR included mucosal ablation and placement of interrupted stitches at the anastomosis. Follow-up was performed at 6 weeks, 3 months and 6 months. The primary outcome was mean % absolute weight loss at 6 months assessed by clinicians blinded to group assignment. Results: Characteristics were similar between groups: 95% female, mean age 48 years, baseline weight 102 kg and mean GJ diameter 27 mm. Average duration between RYGB and DGJR was approximately 62 months with an average weight gain from nadir of 17 kg. The mean number of stitches placed was 4. Technical success (reduction of the GJ to ≤ 10mm) was achieved in 89% of procedures. Using a per protocol analysis (subjects grouped according to treatment received and including only those who completed the study), mean weight loss for the DGJR and sham groups was 4.7%±5.7 (n=43) and 1.9±5.2% (n=26) (p=0.041).Using a last observation carried forward intent-to-treat analysis, mean 6-month weight loss was 4.2±5.4% (n=50) and 1.9±5.2% (n=27) (p=0.066). The percent of subjects achieving weight loss or weight stabilization was 96% in the DGJR group and 78% in the sham group (p=0.019). Additionally, the DGJR group demonstrated a trend toward improvement in metabolic indexes and a reduction in systolic/diastolic blood pressure (p<0.001). The percent of subjects experiencing one or more gastrointestinal adverse events at any time during follow-up was 37.5% in the DGJR group and 41.4% in the sham control group. For both treatment groups, the most common events were those of nausea, vomiting, constipation and pharyngolaryngeal pain occurring primarily in the early post-procedure period or at the time of follow-up endoscopies. Conclusions: In this prospective, randomized trial DGJR via endoluminal suturing appears safe and we observed more weight loss/stabilization relative to sham controls.
M1362 Obesity Surgery Consequences After Gastric Sleeve, is the Esophagus Suffering? Results of a Cohort Comparative Manometric Study Antonio Orozco-Gamiz INTRODUCTION: Obesity surgery is a trend to treat complications of severe overweight, among metabolic and bone mechanics related diseases. BACKGROUND: Obesity is a health problem that often needs surgical treatment to avoid life-threatening situations, metabolic or musculosqueletal diseases like knee or other diseases, gastric sleeve surgery supress the gastric fundus function as a reservoir to the food AIM: to demonstrate that after gastric sleeve surgery the body of the esophagus suffers, as it acts as a reservoir and works against a narrow surgically created outlet. DESIGN: Prospective cohort of cases and controls. SETTING: single open tertiary multi-referral center INFORMED CONSENT was obtained specifying the purpose of the study, benefits and risks were discussed with all the study subjects INTERVENTIONS: Body mass index, physical measurements, demographic data and esophageal manometry were performed. PATIENTS AND METHODS We studied 80 obese patients, 40 with BMI>35 as controls and 40 surgically treated with gastric sleeve, who were before surgery BMI>35. The manometry was done 3 to 6 months after bariatric surgery. Manometry study consisted with the conventional pull through technique with 5 mL. wet swallows. MAIN OUTCOME MEASUREMENTS: to compare obtained data of the esophageal body and lower esophageal sphincter among the two groups studied. RESULTS: Findings of both groups are described as mean measurements in the table. Gastric sleeve patients showed a notorious decreased activity of the lower body of the esophagus and a decreased basal les pressure and lenght behaving as scleroderma as result of a surgical procedure. Follow up to this changes must be done as a need to avoid damage to the esophageal body and diseases related to longtime exposure to food as cancer. Symptoms related to the esophagus must be considered as consequence of this procedure. Future reports must be considered to avoid damage and limit sequelae Manometrical differences among controls and gastric sleeve
M1360 Utility of Screening Endoscopy for Bariatric Surgery Lois L. Hemminger, Cynthia G. Cline, Abraham M. Panossian, Herbert C. Wolfsen Introduction Society guidelines recommend upper endoscopy in all patients with upperGI-tract symptoms who are to undergo bariatric surgery and for patients being evaluated for Roux-en-Y gastrojejunal bypass and gastric banding regardless of symptoms. Further, abdominal obesity has been implicated as a strong risk factor for Barrett's esophagus. The aim of this study was to determine the type and frequency of abnormalities detected at endoscopy prior to bariatric surgery. Methods We reviewed the records of patients undergoing upper endoscopy prior to bariatric surgery to determine patient demographics including