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Staged laparoscopic gastric bypass in super obese patients
Abstracts: Plenary Session/Surgery for Obesity and Related Diseases / 1 (2005) 222–283
cacy data with 1–3 years’ follow-up were available for a subset of 86 patients. For these patients, the baseline mean age was 45.3 years (range 19 –70), baseline weight was 130 kg (range 86 –192), and baseline body mass index (BMI) was 45.7 kg/m2 (range 35– 64). The number of adjustments was tallied and analyzed with respect to weight loss (using analysis of variance). Results: At 18 months (n ⫽ 19), the mean percentage of estimated weighth loss was 60.3%, and the mean reduction in BMI was 13.1 kg/m2. On average, patients had 2.27 (range 0 – 8) adjustments per year. For each additional adjustment per year, patients experienced a mean of 2.86% improved excess weight loss (p ⫽ 0.0487) and a mean decrease in BMI of 0.49 kg/m2 (data adjusted for baseline weight). Conclusions: A statistically significant association was found between the number of adjustments per year and weight loss. Patients who underwent more adjustments experienced improved weight loss compared with those who had fewer adjustments. It seemed to take a few adjustments for each patient to sense the right amount of restriction. Each extra visit also provided an opportunity to reinforce appropriate lifestyle changes that are important for longterm weight loss. PII: S1550-7289(05)00152-8
23.
LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING— LONG-TERM FAILURE Marcos L. Vilas-Boas, M.D., Heitor P. Povoas, M.D., Osiris C. Casais, M.D., Manuela Andrade, M.D., Hospital Santo Amaro, Salvador, Brazil. Purpose: Laparoscopic adjustable gastric banding (LAGB) is a technique with relatively few early complications and a low mortality. However, the long term follow-up of the LAGB procedure has shown inferior results compared with gastric bypass and malabsortive procedures. Methods: From August 1999 to March 2004, 181 patients underwent LAGB. We analyzed the first 100 consecutive cases with 98% having follow-up of 3–5 years. Of the 181 patients, 79 were women and 21 were men, with a mean age 35 years, preoperative weight of 130 kg, and body mass index of 46 kg/m2. The most prevalent comorbid conditions were dyslipidemia (51%), hypertension (47%), and type II diabetes (23%). We considered ⬍40% excess weight loss (EWL) as treatment failure. Results: Twenty-five percent of these patients had the band surgically removed. The indications for band removal were ⬍40% EWL (n ⫽ 10), erosion (n ⫽ 8), esophageal dysmotility (n ⫽ 3), displacement (n ⫽ 1), recurrent esophagitis (n ⫽ 1), psychological intolerance (n ⫽ 1), and gastric perforation (n ⫽ 1). These patients had conversion to gastric bypass (n ⫽ 12), band removal only (n ⫽ 8), and conversion to biliopancreatic diversion (n ⫽ 5). Of the 75 patients with have the band still in place, the average EWL was 55% ⫾ 26%. However 22% of these patients continued to have an EWL of ⬍40%. Conclusions: LAGB has an overall rate of failure (41%) for the treatment of morbid obesity. This high rate of unsuccessful weight control is related to long-term complications of the band and probably due to esophageal alterations that requires frequent band deflation with loss of food restriction. PII: S1550-7289(05)00153-X
233
24.
STAGED LAPAROSCOPIC GASTRIC BYPASS IN SUPER OBESE PATIENTS Faisal G. Qureshi M.D., Joy Collins, M.D., Debra Taylor, R.N., Bethany Sacks, M.D., Pandu Yenumula, M.D., Laura Velcu, M.D., Brian Lane, M.D., Samer Mattar, M.D., Philip R. Schauer, M.D., University of Pittsburgh Medical Center, Pittsburgh, PA. Purpose: Bariatric surgery in super obese patients (body mass index [BMI] ⬎60 kg/m2) has been associated with greater morbidity and mortality. One maneuver to reduce these risks is to perform a staged gastric bypass. We evaluated our outcomes in patients undergoing two-stage gastric bypass. Methods: A retrospective review of all super obese patients undergoing laparoscopic sleeve gastrectomy (stage I) and those undergoing completion laparoscopic Roux-en-Y gastric bypass (stage II) was performed. Demographics, excess weight loss (EWL), comorbid conditions, and complications were studied. The data are presented as the mean ⫾ SD. Results: A total of 126 patients (54% women) underwent stage I and 31 patients (58% women) underwent the completion stage II procedure within 12 ⫾ 4.5 months. The American Society of Anesthesiologists score and preoperative BMI had significantly improved after the first stage (see Table). Both groups had a similar EWL, and stage II patients had a total EWL of 62%. Fewer preoperative comorbid factors were present in Stage II patients, but in both groups 42–79% of obesity-related conditions had resolved within 6 months. The complication rate was similar in both groups, and two conversions were required in each group. Age (yrs)
Stage I (n ⫽ 126) Stage II (n ⫽ 31) p
49 ⫾ 10.9
Follow up (mths)
ASA
Preop BMI kg/m2
EWL (%)
Preoperative Comorbid Conditions
8 ⫾ 0.5
3.5 ⫾ 0.7
65.5 ⫾ 9.3
36.6 ⫾ 12.7
9.4 ⫾ 3.4
51 ⫾ 1.6
6.4 ⫾ 0.9
2.6 ⫾ 0.7
48.8 ⫾ 7.2
40.6 ⫾ 8.2
6.6 ⫾ 3.2
0.05
⬍0.001
⬍0.001
⬍0.001
⫽0.09
⬍0.001
Conclusions: Staged laparoscopic gastric bypass is a viable option in the treatment of super morbid obesity. Longer follow-up is required to evaluate this technique further. PII: S1550-7289(05)00154-1
25.
VAGAL AFFERENT DISCHARGE IN SLEEVE GASTRECTOMY Tomasz Rogula, M.D., Ph.D., Ahmad Assalia, M.D., Federico Cuenca-Abente, M.D., Kazuki Ueda, M.D., Ph.D., Michel Gagner, M.D., Division of Laparoscopy and Department of Surgery, Weill-Cornell College of Medicine, New York-Presbyterian Hospital, New York, NY. Purpose: The vagus autonomic reflexes elicited by stomach dilation and presence of food may control satiety. Sleeve gastrectomy effectively reduces excess weight; however, the physiology remains unclear. We analyzed the activity of the vagal nerve in response to stomach distension after creation of a proximal gastric pouch and sleeve gastrectomy. Methods: A total of 20 anesthetized Wistar rats weighing 250 – 300 g were studied. A latex balloon was placed in the stomach and connected to a distension control device. The balloons were in-
cacy data with 1–3 years’ follow-up were available for a subset of 86 patients. For these patients, the baseline mean age was 45.3 years (range 19 –70), baseline weight was 130 kg (range 86 –192), and baseline body mass index (BMI) was 45.7 kg/m2 (range 35– 64). The number of adjustments was tallied and analyzed with respect to weight loss (using analysis of variance). Results: At 18 months (n ⫽ 19), the mean percentage of estimated weighth loss was 60.3%, and the mean reduction in BMI was 13.1 kg/m2. On average, patients had 2.27 (range 0 – 8) adjustments per year. For each additional adjustment per year, patients experienced a mean of 2.86% improved excess weight loss (p ⫽ 0.0487) and a mean decrease in BMI of 0.49 kg/m2 (data adjusted for baseline weight). Conclusions: A statistically significant association was found between the number of adjustments per year and weight loss. Patients who underwent more adjustments experienced improved weight loss compared with those who had fewer adjustments. It seemed to take a few adjustments for each patient to sense the right amount of restriction. Each extra visit also provided an opportunity to reinforce appropriate lifestyle changes that are important for longterm weight loss. PII: S1550-7289(05)00152-8
23.
LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING— LONG-TERM FAILURE Marcos L. Vilas-Boas, M.D., Heitor P. Povoas, M.D., Osiris C. Casais, M.D., Manuela Andrade, M.D., Hospital Santo Amaro, Salvador, Brazil. Purpose: Laparoscopic adjustable gastric banding (LAGB) is a technique with relatively few early complications and a low mortality. However, the long term follow-up of the LAGB procedure has shown inferior results compared with gastric bypass and malabsortive procedures. Methods: From August 1999 to March 2004, 181 patients underwent LAGB. We analyzed the first 100 consecutive cases with 98% having follow-up of 3–5 years. Of the 181 patients, 79 were women and 21 were men, with a mean age 35 years, preoperative weight of 130 kg, and body mass index of 46 kg/m2. The most prevalent comorbid conditions were dyslipidemia (51%), hypertension (47%), and type II diabetes (23%). We considered ⬍40% excess weight loss (EWL) as treatment failure. Results: Twenty-five percent of these patients had the band surgically removed. The indications for band removal were ⬍40% EWL (n ⫽ 10), erosion (n ⫽ 8), esophageal dysmotility (n ⫽ 3), displacement (n ⫽ 1), recurrent esophagitis (n ⫽ 1), psychological intolerance (n ⫽ 1), and gastric perforation (n ⫽ 1). These patients had conversion to gastric bypass (n ⫽ 12), band removal only (n ⫽ 8), and conversion to biliopancreatic diversion (n ⫽ 5). Of the 75 patients with have the band still in place, the average EWL was 55% ⫾ 26%. However 22% of these patients continued to have an EWL of ⬍40%. Conclusions: LAGB has an overall rate of failure (41%) for the treatment of morbid obesity. This high rate of unsuccessful weight control is related to long-term complications of the band and probably due to esophageal alterations that requires frequent band deflation with loss of food restriction. PII: S1550-7289(05)00153-X
233
24.
STAGED LAPAROSCOPIC GASTRIC BYPASS IN SUPER OBESE PATIENTS Faisal G. Qureshi M.D., Joy Collins, M.D., Debra Taylor, R.N., Bethany Sacks, M.D., Pandu Yenumula, M.D., Laura Velcu, M.D., Brian Lane, M.D., Samer Mattar, M.D., Philip R. Schauer, M.D., University of Pittsburgh Medical Center, Pittsburgh, PA. Purpose: Bariatric surgery in super obese patients (body mass index [BMI] ⬎60 kg/m2) has been associated with greater morbidity and mortality. One maneuver to reduce these risks is to perform a staged gastric bypass. We evaluated our outcomes in patients undergoing two-stage gastric bypass. Methods: A retrospective review of all super obese patients undergoing laparoscopic sleeve gastrectomy (stage I) and those undergoing completion laparoscopic Roux-en-Y gastric bypass (stage II) was performed. Demographics, excess weight loss (EWL), comorbid conditions, and complications were studied. The data are presented as the mean ⫾ SD. Results: A total of 126 patients (54% women) underwent stage I and 31 patients (58% women) underwent the completion stage II procedure within 12 ⫾ 4.5 months. The American Society of Anesthesiologists score and preoperative BMI had significantly improved after the first stage (see Table). Both groups had a similar EWL, and stage II patients had a total EWL of 62%. Fewer preoperative comorbid factors were present in Stage II patients, but in both groups 42–79% of obesity-related conditions had resolved within 6 months. The complication rate was similar in both groups, and two conversions were required in each group. Age (yrs)
Stage I (n ⫽ 126) Stage II (n ⫽ 31) p
49 ⫾ 10.9
Follow up (mths)
ASA
Preop BMI kg/m2
EWL (%)
Preoperative Comorbid Conditions
8 ⫾ 0.5
3.5 ⫾ 0.7
65.5 ⫾ 9.3
36.6 ⫾ 12.7
9.4 ⫾ 3.4
51 ⫾ 1.6
6.4 ⫾ 0.9
2.6 ⫾ 0.7
48.8 ⫾ 7.2
40.6 ⫾ 8.2
6.6 ⫾ 3.2
0.05
⬍0.001
⬍0.001
⬍0.001
⫽0.09
⬍0.001
Conclusions: Staged laparoscopic gastric bypass is a viable option in the treatment of super morbid obesity. Longer follow-up is required to evaluate this technique further. PII: S1550-7289(05)00154-1
25.
VAGAL AFFERENT DISCHARGE IN SLEEVE GASTRECTOMY Tomasz Rogula, M.D., Ph.D., Ahmad Assalia, M.D., Federico Cuenca-Abente, M.D., Kazuki Ueda, M.D., Ph.D., Michel Gagner, M.D., Division of Laparoscopy and Department of Surgery, Weill-Cornell College of Medicine, New York-Presbyterian Hospital, New York, NY. Purpose: The vagus autonomic reflexes elicited by stomach dilation and presence of food may control satiety. Sleeve gastrectomy effectively reduces excess weight; however, the physiology remains unclear. We analyzed the activity of the vagal nerve in response to stomach distension after creation of a proximal gastric pouch and sleeve gastrectomy. Methods: A total of 20 anesthetized Wistar rats weighing 250 – 300 g were studied. A latex balloon was placed in the stomach and connected to a distension control device. The balloons were in-