Laparoscopic Roux-en-Y Gastric Bypass After Failed Vertical Banded Gastroplasty: a Multicenter Experience with 203 Patients.

BACKGROUND: Vertical banded gastroplasty (VBG) has long been the main restrictive procedure for morbid obesity but has many long-term complications for which conversion to Roux-en-Y gastric bypass (RYGBP) is often considered the best option. METHODS: This series regroups patients operated on by three different surgeons in four different centers. All data were collected prospectively, then pooled and analyzed retrospectively. RESULTS: Out of 2,522 RYGBP performed between 1998 and 2010, 538 were reoperations, including 203 laparoscopic RYGBP after VBG. There were 175 women and 28 men. The mean BMI before VBG was 43.2 ± 6.3, and the mean BMI before reoperation was 37.4 ± 8.3. Most patients had more than one indication for reoperation and/or had regained significant weight. There was no conversion to open surgery. A total of 24 patients (11.8 %) developed complications, including nine (4.5 %) who required reoperation and one death. With a follow-up of 88.9 % after 8 years, the mean BMI after 1, 3, 5, 7, and 9 years was 29.1, 28.8, 28.7, 29.9, and 28.8, respectively. CONCLUSIONS: On the basis of this experience, the largest with laparoscopic reoperative RYGBP after failed VBG, we conclude that this procedure can safely be performed in experienced hands, with weight loss results similar to those observed after primary RYGBP. In patients with too difficult an anatomy below the cardia, dividing the esophagus just above the esophago-gastric junction and performing an esophagojejunostomy may be a safe alternative to converting to a Scopinaro-type BPD, obviating the additional long-term risks associated with malabsorption.

Intermediate results of health related quality of life after vertical banded gastroplasty

OBJECTIVES: The purpose of this study is to evaluate (a) health-related quality of life (HRQL) after vertical banded gastroplasty (VBG) (Mason) and (b) predictors of HRQL. SUBJECTS: Eighty-two consecutive patients were assessed preoperatively and then after 6, 12 and 24 months. Patients filled out questionnaires for subjective appraisal of HRQL (physical well-being, mood, physical performance, perceived health, social support and coping/adjustment). RESULTS: The greatest improvement in weight and HRQL was seen within 6 months of surgery. Twenty-four months after VBG weight reduction (P<0.05), perceived health (P<0.05), physical well-being (P<0.05), physical performance (P<0.05), mood (P<0.05), coping/adjustment (P<0.05) continued to be better than before surgery. Preoperative binge eating was the most important predictor of HRQL. CONCLUSION: Two years after VBG weight loss and a significant improvement of HRQL can be found. HRQL and weight loss are not associated in terms of outcome, indicating that weight loss alone may not be enough to improve HRQL.

[Mason vertical gastroplasty in treatment of morbid obesity. Results of a prospective clinical study]

Morbid obesity (body mass index > 40 kg/m2) is a risk factor for cardiovascular, pulmonary, metabolic, neoplastic, and psychologic sequelae. In the present prospective clinical study 65 patients (11 men, 54 women) underwent vertical banded gastroplasty (Mason procedure) from June 1994 to October 1997. The median age was 41 +/- 5.3 years (range 18-69; n = 65). Preoperative body weight was 135 +/- 23 kg (96-229; n = 65), excess body weight in kg was 75 +/- 6.9 (44-155; n = 65) or in % 126 +/- 10 (78-223; n = 65) and BMI was 49 +/- 7.4 kg/m2 (39-69; n = 65). Mean hospital stay was 9.7 +/- 2.4 days (6-18; n = 65). Hospital mortality was 0% (0/65). Early complications were vomiting (30%) and problems in wound healing (15%; n = 65). Late complications (> 30 days) were incisional hernias (13.8%) and staple-line disruptions (12.3%; n = 65) with a reoperation rate of 23% (15/65). Median follow-up was 15.0 +/- 5.2 months (2-42) with a follow up rate of 100%. Mean weight loss after 12 months was 38.5 +/- 17 kg (30-98; n = 34) (P < 0.0001) and loss of excessive body weight 65 +/- 10% (57-86; n = 34), respectively (P < 0.0001). Cardiovascular risk factors (hypertension, diabetes, hyperlipidemia) were significantly improved within 12 months (n = 34). Vertical banded gastroplasty (Mason procedure)--well established for 20 years--is a good, safe therapy for morbid obesity if strict indications for operation are observed and if there is multidisciplinary long-term follow-up. Comorbid risk factors are considerably reduced and a long-term weight loss of more than 50% can be achieved without the risk of pathological metabolic changes.

Altered plasma response to zinc and iron tolerance test after Roux-en-Y gastric bypass

Background: The duodenum and proximal jejunum are excluded after Roux-en-Y gastric bypass but these intestinal sites are where iron and zinc are most absorbed. Therefore, they are among the nutrients whose digestive and absorptive process can be impaired after surgery. The aim of the present study was to investigate the iron and zinc plasma response to a tolerance test before and after bariatric surgery. The study was performed at Sao Paulo University School of Medicine of Ribeirao Preto, Brazil. Methods: In a longitudinal paired study, 9 morbidly obese women (body mass index >= 40 kg/m(2)) underwent an iron and zinc tolerance test before and 3 months after surgery. The iron and zinc levels were determined at 0, 1, 2, 3, and 4 hours after a physiologic unique oral dose. The mineral concentrations in die plasma and 24-hour urine sample were assayed using an atomic absorption spectrophotometer. The anthropometric measurements and 3-day food record were also evaluated. A linear mixed model was used to compare the plasma concentration versus interval after the oral dose, before and after surgery. Results: The pre- and postoperative test results revealed a significantly lower plasma zinc response (P <.01) and a delayed response to iron intake after surgery. The total plasma iron concentration area, during the 4 hours, was not different after surgery (P >.05). The 24-hour urinary iron and zinc excretion did not differ between the pre- and postoperative phases. Conclusion: The present data showed a compromised response to the zinc tolerance test after gastric bypass surgery, suggesting an impaired absorption of zinc. More attention must be devoted to zinc nutritional status after surgery. (Surg Obes Relat Dis 2011;7:309-314.) (C) 2011 American Society for Metabolic and Bariatric Surgery. All rights reserved.

Effects of Inspiratory Muscle Training on Muscular and Pulmonary Function After Bariatric Surgery in Obese Patients

This study seeks to assess the effect of inspiratory muscle training (IMT) on pulmonary function, respiratory muscle strength, and endurance in morbidly obese patients submitted to bariatric surgery. Thirty patients were randomly assigned to sham muscular training, or to IMT with a threshold device (40% of maximum inspiratory pressure, MIP), for 30 min/day, from the 2nd until 30th postoperative (PO) day. All of them were submitted to a standard respiratory kinesiotherapy and early deambulation protocol. Data on spirometry, maximum static respiratory pressures, and respiratory muscle endurance were collected on the PO days 2, 7, 14, and 30 in a blinded matter. IMT enabled increases in PO MIP and endurance, and an earlier recovery of the spirometry parameters FEV(1), PEF, and FEF(25-75%). Comparing to preoperative values, MIP was increased by 13% at the 30th PO day in the trained group, whereas control group had a reduction of 8%, with higher values for the IMT group (30th PO, IMT-130.6 +/- 22.9 cmH(2)O; controls-112.9 +/- 25.1 cmH(2)O; p < 0.05). Muscular endurance at the 30th PO day was increased in the trained group comparing to preoperative value (61.5 +/- 39.6 s vs 114.9 +/- 55.2 s; p < 0.05), a finding not observed in the control group (81.7 +/- 44.3 vs 95.2 +/- 42.0 s). IMT improves inspiratory muscle strength and endurance and accounts for an earlier recovery of pulmonary airflows in morbidly obese patients submitted to bariatric surgery.

Seroconvertion to hepatitis B vaccine after weight reduction in obese non-responder

Decreased responses to hepatitis B vaccine have been associated with some host conditions including obesity. Susceptible non-responders to a primary three-dose vaccine series should be revaccinated. Those who maintain a non-responder condition after revaccination with three vaccine doses are unlikely to develop protection using more doses. This is a description of an obese woman who received six doses of hepatitis B vaccine and persisted as a non-responder. She was submitted to a vertical banded gastroplasty Roux-en-Y gastric bypass Capellas's technique. After weight reduction, she received three additional doses of vaccine and seroconverted. Further studies should help clarify the need to evaluate antibody levels and eventually revaccinate the increasing population of individuals who undergo weight reduction.

Complicação da banda gástrica ajustável videolaparoscópica para tratamento da obesidade mórbida: extrusão da banda

Various options for surgical treatment of morbid obesity have been developed with varying results: vertical banded gastroplasty with intestinal by-pass, disabsorptive surgeries and laparoscopic adjustable gastric banding. Although all of them have been effective in weight loss, lower rates of early and late postoperative complications have been described in some procedures. Laparoscopic adjustable silicone gastric banding (LASGB) has a similar principle as vertical banded gastroplasty and it is a minimally invasive procedure, with low systemic and operative problems, but not free of them. We report two rare cases of this complications of LASGB.

Cirugía bariatrica : gastrogastroplastia laparoscopica y bypass gástrico en pacientes con obesidad mórbida

La obesidad es un problema de salud global siendo la cirugía bariatrica el mejor tratamiento demostrado. El Bypass gástrico (BGYR) es el método más utilizado que combina restricción y malabsorcion; sin embargo los procedimientos restrictivos se han popularizado recientemente. La Gastro-gastroplastia produce restricción gástrica reversible por medio de un pouch gástrico con anastomosis gastrogástrica y propusimos su evaluación Métodos: Estudio retrospectivo no randomizado que evaluó archivos de pacientes con GG y BGYR laparoscópicos entre febrero de 2008 y Abril de 2011 Resultados: 289 pacientes identificados: 180 GG y 109 BGYR de los cuales 138 cumplieron criterios de inclusión, 77 (55.8%) GG y 61 (44,2%) BGYR, 18 (13%) hombres y 120 (87%) mujeres. Para GG la mediana del peso inicial fue 97,15 (± 17,3) kg, IMC inicial de 39,35 (± 3,38) kg/m2 y exceso de peso de 37,1 (±11,9). La mediana de IMC a los 1, 6 y 12 meses fue 34,8 (±3,58) kg/m2, 30,81 (±3,81) kg/m2, 29,58 (±4,25) kg/m2 respectivamente. La mediana de % PEP 1, 6 y 12 meses fue 30,9 (±14,2) %, 61,88 (±18,27) %, 68,4 (±19,64) % respectivamente. Para BGYR la mediana del peso inicial fue 108,1 (± 25,4) kg, IMC inicial 44,4 (± 8,1) y exceso de peso de 48,4 (±15,2) %. La mediana de IMC a los 1, 6 y 12 meses fue 39 (±7,5) kg/m2, 33,31 (±4,9) kg/m2, 30,9 (±4,8) kg/m2 respectivamente. La mediana de % PEP 1, 6 y 12 meses fue 25,9 (±12,9) %, 61,87 (±18,62) %, 71,41 (±21,09) % respectivamente. Seguimiento a un año Conclusiones: La gastro-gastroplastia se plantea como técnica restrictiva, reversible, con resultados óptimos en reducción de peso y alternativa quirúrgica en pacientes con obesidad. Son necesarios estudios a mayor plazo para demostrar mantenimiento de cambios en el tiempo

Cirugía bariatrica : gastrogastroplastia laparoscópica y bypass gástrico en pacientes con obesidad mórbida

La obesidad es un problema de salud global siendo la cirugía bariatrica el mejor tratamiento demostrado. El Bypass Gástrico (BGYR) es el método más utilizado que combina restricción y malabsorcion; sin embargo los procedimientos restrictivos se han popularizado recientemente. La Gastro-gastroplastia produce restricción gástrica reversible por medio de un pouch gástrico con anastomosis gastrogástrica y propusimos su evaluación Métodos: Estudio retrospectivo no randomizado que evaluó archivos de pacientes con GG y BGYR laparoscópicos entre Febrero de 2008 y Abril de 2011 Resultados: 289 pacientes identificados: 180 GG y 109 BGYR de los cuales 138 cumplieron criterios de inclusión, 77 (55.8%) GG y 61 (44,2%) BGYR, 18 (13%) hombres y 120 (87%) mujeres. Para GG la mediana del peso inicial fue 97,15 (± 17,3) kg, IMC inicial de 39,35 (± 3,38) kg/m2 y exceso de peso de 37,1 (±11,9). La mediana de IMC a los 1, 6 y 12 meses fue 34,8 (±3,58) kg/m2, 30,81 (±3,81) kg/m2, 29,58 (±4,25) kg/m2 respectivamente. La mediana de % PEP 1, 6 y 12 meses fue 30,9 (±14,2) %, 61,88 (±18,27) %, 68,4 (±19,64) % respectivamente. Para BGYR la mediana del peso inicial fue 108,1 (± 25,4) kg, IMC inicial 44,4 (± 8,1) y exceso de peso de 48,4 (±15,2) %. La mediana de IMC a los 1, 6 y 12 meses fue 39 (±7,5) kg/m2, 33,31 (±4,9) kg/m2, 30,9 (±4,8) kg/m2 respectivamente. La mediana de % PEP 1, 6 y 12 meses fue 25,9 (±12,9) %, 61,87 (±18,62) %, 71,41 (±21,09) % respectivamente. Seguimiento a un año. Conclusiones: La gastro-gastroplastia se plantea como técnica restrictiva, reversible, con resultados óptimos en reducción de peso y alternativa quirúrgica en pacientes con obesidad. Son necesarios estudios a mayor plazo para demostrar mantenimiento de cambios en el tiempo.

Família e obesidade: um estudo psicanalítico a partir do discurso de pacientes submetidos a gastroplastia

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Resultados da cirurgia bariátrica e metabólica: gastrectomia vertical versus gastroplastia vertical com derivação em Y-de-Roux. Ensaio clínico prospectivo

Objetivos: Avaliar a equivalência da operação gastrectomia vertical com anel (GVA), em relação à operação gastroplastia vertical com anel e derivação gástrica em Y-de-Roux (DGA), na indução de perda ponderal e modificação da composição corporal em obesas mórbidas. Verificar os impactos laboratoriais e clínicos da GVA sobre as principais doenças associadas à obesidade mórbida, e a ocorrência de complicações, em comparação à DGA. Métodos: Ensaio clínico prospectivo não-randomizado, incluindo 65 mulheres obesas mórbidas, distribuídas em dois grupos, GVA (n = 33) e DGA (n = 32). Operadas consecutivamente, pelo mesmo cirurgião, por via laparotômica. Os parâmetros avaliados foram antropométricos; composição corporal, por meio de bioimpedância elétrica; laboratoriais; efeitos sobre as doenças pré-existentes e complicações. Resultados: Ocorreu perda de peso expressiva (p = 0,0000), redução do índice de massa corporal - IMC (p = 0,0000) e cintura abdominal (p = 0,0000) em ambos grupos. O índice cintura/quadril diminuiu (p = 0,0000) após ambas intervenções. A perda do excesso de IMC foi de 86,05% ± 14,2 no grupo GVA e 85,91 ± 15,71 no grupo DGA. A variação da gordura corporal foi de -35,84% ± 8,66 no grupo GVA e de -37,64% ± 9,62 no grupo DGA. A redução dos níveis de triglicerídios (p = 0,0222) foi mais expressiva no grupo DGA. O grupo DGA atingiu os alvos terapêuticos para o colesterol-LDL com maior freqüência (p = 0,0005), que o grupo GVA. Intolerância à glicose, diabetes mellitus tipo 2, hipertensão arterial sistêmica, esteatose hepática e síndrome metabólica, foram controladas de forma semelhante entre as técnicas. Anemia foi mais prevalente no grupo DGA (p=0,0033) e a esofagite erosiva, no grupo GVA (p = 0,0032). Não houve diferença na formação de cálculos biliares entre os grupos. Conclusões: A GVA é tão efetiva quanto a DGA em induzir perda ponderal e modificação favorável da composição corporal. A GVA é menos efetiva no controle da dislipidemia, em relação à DGA. GVA acarreta anemia em menor freqüência e, esofagite erosiva de maneira mais freqüente, que a DGA. GVA não é mais segura que a DGA, mas deve ser considerada intervenção bariátrica efetiva como segunda opção.

Study of the patency of different peritoneal drains used prophylactically in bariatric surgery

AIM: To compare the performance of different types of abdominal drains used in bariatric surgery. METHODS: A vertical banded Roux-en-Y gastric bypass was performed in 33 morbidly obese patients. Drainage of the peritoneal cavity was performed in each case using three different types of drain selected in a randomized manner: a latex tubular drain, a Watterman tubulolaminar drain, and a silicone channeled drain. Drain permeability, contamination of the drained fluid, ease of handling, and patient discomfort were evaluated postoperatively over a period of 7 d. RESULTS: The patients with the silicone channeled drain had larger volumes of drainage compared to patients with tubular and tubulolaminar drains between the third and seventh postoperative days. In addition, a lower incidence of discomfort and of contamination with bacteria of a more pathogenic profile was observed in the patients with the silicone channeled drain. CONCLUSION: The silicone channeled drain was more comfortable and had less chance of occlusion, which is important in the detection of delayed dehiscence. (C) 2009 The WJG Press and Baishideng. All rights reserved.

Obesity and GERD: pathophysiology and effect of bariatric surgery

Epidemiologic, endoscopic, and pathophysiologic studies document the relationship between obesity and gastroesophageal reflux disease (GERD). Increased body mass index and accumulation of visceral fat are associated with a two- to threefold increased risk of developing reflux symptoms and esophageal lesions. Given this association, many studies were designed to evaluate the outcome of reflux symptoms following conventional and surgical treatment of obesity. Among bariatric procedures, gastric sleeve and banded gastroplasty were shown to have no effect or even worsen reflux symptoms in the postoperative setting. Gastric banding improves reflux symptoms and findings (endoscopic and pH-measured distal esophageal acid exposure) in many patients, but is associated with de novo reflux symptoms or lesions in a considerable proportion of patients. To date, Roux-en-Y gastric bypass is the most effective bariatric procedure that consistently leads to weight reduction and improvement of GERD symptoms in patients undergoing direct gastric bypass and among those converted from restrictive bariatric procedures to gastric bypass.

Acrodermatitis due to zinc deficiency after combined vertical gastroplasty with jejunoileal bypass: case report

CONTEXT: Nutritional complications may occur after bariatric surgery, due to restriction of food intake and impaired digestion or absorption of nutrients. CASE REPORT: After undergoing vertical gastroplasty and jejunoileal bypass, a female patient presented marked weight loss and protein deficiency. Seven months after the bariatric surgery, she presented dermatological features compatible with acrodermatitis enteropathica, as seen from the plasma zinc levels, which were below the reference values (34.4 mg%). The skin lesions improved significantly after 1,000 mg/day of zinc sulfate supplementation for one week. CONCLUSIONS: The patient's evolution shows that the multidisciplinary team involved in surgical treatment of obesity should take nutritional deficiencies into consideration in the differential diagnosis of skin diseases, in order to institute early treatment.