abstracts of the first congress of the international federation for the surgery of obesity

Obesity Surgery, 6, 296-324

Abstracts of the First Congress of the International Federation for the Surgery of Obesity

1. Eleven Years Experience with Vertical Banded Gastroplasty

Emanuel He//, MD, Karl Miller, MD

Krankenhaus Hallein and Second Surgical Department, Landeskrankenansfalfen Salzburg, Austria

Since 1985 vertical banded gastroplasty has been performed in a consecutive series of 360 morbidly obese patients. Two years after operation the average weight loss was 46 kg or 67% of initial overweight. There was one postoperative and two late deaths. The reintervention rate was 2% per year for the first 5 years. In the treatment of morbid obesity vertical banded gastroplasty is an effective procedure, rapid and simple to perform and without irreversible changes in the digestive tract.

2. Long-Term Results of Vertical Banded Gastroplasty (VBG) in a French Center

Vincent frering, Dominique Honnorat, Christian Partensky

Service de Chirurgie Digestive, Hipita Edouard Hewiof, Place d’arsonval, 6943 7 Lyon cedex 03, France

In spite of the high prevalence of obesity in France, similar to other industrialized areas, surgery for morbid obesity is uncommon in this country. The purpose of this study was to analyse the long-term results of VBG.

Material and methods: From October 1987 to March 1996, 110 patients had VBG for morbid obesity. Sixty-two were analysed, seven men and 55 women, from 20- to 68-years-old (mean: 37.4 ? 9-years-old), operated in the first 5 years and with at least a 24-months follow-up. Preoperative mean weight and Body Mass Index (BMI) were respectively 123 ? 27 kg and 47.3 ? 9.8 kg m-‘. Diseases associated were diabetes mellitus (n = 31), hypertension (n = 29), hyp erc o es erolemia h 1 t (n = lo), hypertri- glyceridemia (n = 21) and joint diseases (n = 18).

Results: VBG was performed with a 50mm long Marlex@ mesh in 20 cases and with a 47-50 mm long ring silastic in 42 cases. One patient died 3 years later

296 Obesity Surgery, 6, 1996

of alcoholic liver cirrhosis and four were lost to follow-up. Mean follow-up was 31 months. Mean weight and BMI were respectively 86 I!Z 21 kg (p < 0.001) and 32.1 ? 9.8 kgm-’ (p < 0.001). Ring removal was achieved in three cases, one because of neurologic complications and two on patient’s request. Eight patients (13%) failed to have satisfactory weight loss. Diabetes mellitus and hypertension have resolved in 19 cases, hypercholesterolemia in seven and hyper- triglyceridemia in 11.

Conclusion: VBG provides a significant weight loss which reduces frequency of medical disorders associated with obesity. This result was achieved in 87% of patients. Surgical procedure for morbid obesity must be concerted with endocrinologist, pyschiatrist and surgical staff for good long-term results.

3. Vertical Banded Gastroplasty: First Experience in Russia

Yury 1. Yashkov, MD, Andrew D. Timoshin, MD, Tatyana A. Oppel

National Research Cenfre of Surgery, Moscow, Russia

The two first vertical banded gastroplasties (VBG) in Russia have been done in November 1992. Previous bariatric surgical procedures, performed in other clinics in Russia, were open gastric banding and jejunoileal bypass. Until February 1996 20 patients with morbid obesity were operated on by VBG. There were four men and women aged 33-59 years with average preoperative weight 134.4 kg (range 95-183).

Nineteen operations have been performed according to Mason’s technique using TA-90BN (Auto Suture) vertical stapling; the remaining one - with GIA-90 (Auto Suture) transsection of stomach. During the last operations we created a pouch volume of 15- 20 ml having measured it under pressure of 77 cc H,O with stoma circumference 5.0cm. There were 15 simultaneous operations (cholecystectomy - ten, hernioplasty - eight, ovarial and uterine tube cystec- tomy - one both). All patients received antibiotics and heparin.

There were no fatal outcomes. Early postoperative

0 1996 Rapid Science Publishers

Abstracts

is easy. We place the instrument on the anterior surface of the stomach, which is kept in tension between two forceps and the large naso-gastric tube, and we place the CEEA directly. The operation is concluded with the placing around the lowest part of the pouch, through the gastric window, of a Goretex band 1.5 cm wide and 0.6 mm thick. The band varies according to the thickness of the anatomic structures which are inside the 11 mm tube. The length of the band is variable between 6 and 8 cm, because the circumference of the band varies according to the thickness of the tissue encompassed in the band which inside is a naso-gastric tube, 11 mm in diameter. If the band is tight don’t squeeze the tissue. In this way we standardize the volume of the pouch at about 30cc and the neo-pyloris diameter at II mm. The introduction of the new instrument and the modifications of the technique, change short- term operational-time and thereby makes the operation safer for the patient with fewer anaesthetic complications.

complications were: haemothorax after subclavian vein catheterization in one patient, minor wound infection (three), perianal abscess in patient with diabetus mellitus (one). One relaparotomy for suspicion of peritonitis has been done, no complications were revealed.

All patients were followed-up. The mean excess weight loss was: at 6 months (15 patients) - 43.7%, at 1 year (12) - 51.6%, at 2 years (eight) - 50.4%. Up to the present we have noted weight stabilization in the first ten patients. Their average final excess weight loss was 52.7% with nadir 60.5%. Two patients revealed staple line disruptions with essential weight regain. Other late postoperative complications included five incisional hernias. There were no serious metabolic consequences in our group.

Our first impression of VBG is favourable. Standardi- zation of technique and the gaining of further experience are necessary before passing final judgment on its effects.

4. Modified Mason’s Vertical Gastroplasty For Severe Obesity

Enrico Amenta, MD, Stefano Cariani, MD, Mina 5. Laparoscopic Vertical Banded Gastroplasty:

Imperio, MD, Danilo Paradiso, MD First Results of 166 Consecutive Patients

University of Bologna, Third Surgical Department J.L. Al/b, M. Poortmans

(Director Professor Angelo Conti) CHU Tivoli, La Low&e, Belgium

Since 1991, 304 patients have undergone modified Mason’s VBG for severe obesity. The median preoperative BMI was 46.9 kg m-’ (range 32.8-72.1). First of all, we don’t isolate the terminal portion of the oesophagus. We dissect under the lesser omentum into the posterior epiplooic cavity and then, very gently, we open a passage only with the left second finger just above the oesophago-gastric angle and through this hole in the gastrophrenic legament pass a silastic tube. Pulling up the tube we are able to effect a better aemostasis control on the cardia and on the upper portion of the stomach. We have also introduced the use of a new instrument to standardize the placement of the gastric ‘window’ and the pouch volume. This is a steel instrument with two arms placed at 90”. One arm is 9cm and the other one 3 cm long. The end of the short arm is curved and it fits closely on the lesser curve of the stomach where on the inside there is a large naso-gastric tube (II mm in diameter) that the anaesthetist introduces during the intervention, in order to calibrate the neo-pyloris diameter. With this instrument the point of introduction of the trocar of the CEEA 25 at 9 cm from the cardias and 3 cm from the lesser curve

From May 1993 to February 1996, 166 consecutive patients underwent laparoscopic approach for Vertical Banded Gastroplasty.

Patients: Indication for surgery was morbid obesity in all cases but ten (6%) had already underwent other failed procedures (three of them were not obese at the time of laparoscopy). The 163 obese patients were mean 35.1 (20-62) years old, 133 (81.6%) female. Mean pre-operative weight was 118.6 (85-180) kg, mean BMI was 43.5 (36-60).

Operative results: Conversion rate was 1.8% (31 166) for hemorrhage. Mean operative duration was 129min (60-295) but 86 min for the last 60 cases. There were no fatalities. Post-operative morbidity ws 2.4% (four patients including pneumopathy (one), wound infection (two) and MOF (one)). Mean postoperative hospital stay was 4.6 (2-41) days.

Functional follow-up: Mean follow-up duration is 15.2 (l-32) months. Technical failure concerns five patients (3%) including four silastic ring migrations and one stapling failure. Late complications include five occlusions, three esophagitis-pouchitis, four incisional umbilical hernias and one significant psychiatric disorder.

Obesity Surgery, 6, 1996 297

Abstracts

Weight-loss follow-up: Respectively at 6 (n = 116), Staple-line lesions in obesity surgery are well known 12 (n = 83), 18 (n = 56) and 24 (M = 27) months: and have become a serious problem. Rates between

- excess loss (%): 60.4, 78.1, 79.5, 79.9; 1.4-48%, depending on time postoperatively, are pub- - Mean BMI: 31.7, 28.1, 27.8, 27.3; lished. The duplication from 2-4 staple lines decreased - McLean good and excellent results: 69%, 93%, the percentage rate, but did not solve the problem.

92%‘ 91%. Literature shows only one publication regarding a double application of a TA” 90B stapler in order to reduce staple line lesions. Five morbidly obese patients

6. Vertical Banded Gastroplasty For Morbid Obesity: Laparotomy or Coelioscopy? A Randomised Study

Jacques Ansay, Santi Azagara, Martine Goergen

CHU Andre Vesale, Montigny-le-Tilleul, Belgium

Vertical Banded Gastroplasty is a very effective technique for treating morbid obesity. Having good experience in coelioscopy, we succeeded in transposing the exact technique.

A video film shows the steps we systematically performed by laparotomy and by coelioscopy:

l Dissection of the angle of Hiss; l Marking 9 cm under the angle of Hiss; l Gastrolysis in front of the mark; l Creation of a gastric window; l Creation of a gastric pouch; l Calibration of the gastric outlet.

We included 60 cases in a randomized series of Vertical Banded Gastroplasty from March 1995 to January 1996 to compare the results by laparotomy and by coeliscopy. Thirty cases were treated by laparotomy, 30 by coelioscopy. The two series were similar about age, sex, weight and BMI. Three cases were transposed from coelioscopy to laparotomy for technical problems. No difference was found in hospi- talization and mobility. The operating duration was significantly longer for the coelioscopic technique and cost is more expensive. Early complications include two peritonitis by laparotomy and one perforation in the coelioscopic series. There were no deaths in either series. Weight loss is the same till now in the two series. We are waiting for the analysis of the late complications such as incisional hernia, staple-line disruptions etc., the follow-up time up to this point being too short.

treated with SRVG had to be reoperated (4-16 months postoperatively), because of a staple-line lesion following a stoma stenosis. The blood supply of the stomach wall was normal in these five patients, and we were encouraged to place - parallel to the first - a second series of four staple lines with the TA” 90BN stapler. We did not observe any devascu- larization of tissue in the stomach wall. The second step in these five operations was the correct adjustment of the stoma to 12mm in diameter. The postoperative X-ray findings 3-6 months after revision were satisfactory. Regarding these experiences the question arose, are we allowed to fire the TA” 90BN staple twice in a primary SRVG procedure to avoid leakage of the staple line. In early 1996, we performed tests in an animal lab, and we fired the TA” 90B stapler two and three times and placed the staple lines in pig stomachs parallel to the lesser curvature. Amazingly, we did not observe a reduced blood supply in the stomach wall. We treated six animals, three with double application (eight staple lines) and three with triple application (12 staple lines) of the stapler. As a result of these experiences, our first morbidly obese patient underwent SRVG operation in April 1996, and this procedure was performed with a double firing of the TA” 90BN stapler. Postoperatively, the patient’s condition was uneventful. Up to this point we have treated patients in the same way as described above. Postoperatively, the patients are doing well. We did not observe a disruption of the staple line. The follow-up time is much too short to state that staple-line lesions are a thing of the past. However, we are convinced that we have found the right way to reduce staple-line lesions to an acceptable percentage rate in long-term follow-up.

7. Staple-line Ruptures - an Unavoidable 8. Staple-line Disruption in Vertical Banded Problem in Obesity Surgery? Gastroplasty

Hans-Werner Kuhlmann, MD, Anna-M. Wolf, MD, Karl-Erik Svenheden, MD, Lars-Ake Akeson, MD, Burkhard Kortner Carl Holmdahl, MD, lngmar Ntislund, MD, PhD

General Surgery, Evangelisckes Krankenkaus, Kreuzstrasse Departments of Surgery, Skene and Orebro, and Depart-

28, 46535 Dinslaken, Germany ment of Radiology, Skene, Sweden


Abstracts

Table 1. Frequency of staple disruption was removed in three for esophageal reflux (n = 2)

Months since surgery 6 12 24 36 4% and neurologic complication (n = I), and four patients n of examined patients 23 15 31 IO 12 91 required endoscopical dilatation for stenosis of gastro- nofSD 8 4 15 8 5 40

Cumulative frequency (%) 9 13 30 3% 44 44

In earlier studies of Vertical Banded Gastroplasty (VBG), staple disruptions (SD) were reported in only a few per cent or less of cases. A few more recent studies have shown a higher frequency. In order to assertain the true frequency of SD a consecutive series of VBG-patients were examined regarding SD.

In 91 out of 95 patients in a consecutive series of VBG-patients the patency of the staple-lines were examined by a standardized radiological method at different intervals ranging from 6 to 48 months postoperatively.

SD was shown in 40 patients (44%). The diameters were on an average 6mm (range 2-16mm). SD was much more common among women than among men.

Since the patients were examined at different intervals after surgery the numbers in Table 1 thus show the minimal frequency of SD.

SD is an inherent problem of VBG which has been underestimated for a long period of time. SD frequency of at least 44% or more within the first few years cannot be accepted and a change in VBG technique has therefore been carried out.

9. Complications Following Vertical Banded Gastroplasty

Vincent Frering, Christophe Breton, Christian Partensky

Service de Chirurgie Digestive, H;pital Edouard Herriot, Place d’arsonval, 6943 7 Lyon ceder 03, France

Vertical banded gastroplasty (VBG) is increasingly used for weight loss in morbidly obese patients even in France. The aim of this study was to assess complications requiring endoscopical or surgical procedures after VBG.

Methods: From October 1987 to March 1996, 110 VBG were performed. Mean preoperative BMI was 47.5 k 8.4 kg mP2. VBG procedure was performed in 20 patients and silastic ring vertical gastroplasty in 90. There were no postoperative deaths.

Results: Mean follow-up was 21 & 20 months. Four- teen patients were lost to long-term follow-up. Two different groups of complications were observed in 37 patients (33%). The first group of complications are related with gastric restrictive procedure: three patients were reoperated for staple-line disruption, silastic ring

plasty orifice, one patient had surgical procedure for reflux. Eight patients had gastroesophageal reflux alleviated by omeprazole. The second group included parietal complications. Nineteen patients had surgical reparation for incisional hernia: 18/66 patients (27%) with medial incision and l/44 patient (2%) with trans- versal incision. Seven patients had abdominoplasty alone when weight loss was stablized.

Conclusions: These results suggest that close con- tact must be kept after gastric restriction for obesity. Minimal invasive procedure with adjustable gastric ring should decrease parietal morbidity and complications related with stenosis of gastroplasty orifice, but this new procedure requires further evaluations.

10. Stomastenosis as Complication After SRVG

Anna 111. Wolf, MD, Burkhard Kortner, Hans-Werner Kuhlmann, MD

General Surgery, Evangelisches Krankenhaus, Kreuzsfrasse 28, 46535 Dinslaken, Germany

Nine patients suffering from morbid obesity who had been treated successfully with SRVG had to be reoperated due to stomastenosis. The reoperation was necessary at different times after the initial operation (4-16 months). According to a statement by Dr Mason in his lecture (Stockholm 1995) we measured the length of the thread which is held in place by a silastic ring in order to support the outlet. The silastic ring has a length of 5 cm and the thread led through this ring twice needs to be between lo-11 cm long to allow an outlet with a diameter of IO--12mm. In the patients who were reoperated the length of the thread varied from 8.2 to lO.Ocm. In seven patients the cause of stomastenosis can be attributed to the fact that the thread was too short (9.9cm). In five of these nine patients the stomastenosis led to a staple-line rupture and/or pouch-dilatation. This complication made it necessary to set an additional staple-line during the reoperation. After the re-stapling with the TA 90 BNK we inserted a calibration tube generally used when implanting an LAGB. This allowed us to calibrate the stoma diameter to 12 mm in order to prevent another outlet-stenosis from a surgical point of view.

A stomastenosis allows the patients only to eat liquid food and thereby led to an average weight loss of 49 kg (36-62 kg). The initial BMI was between 41 and 55. At the second operation it was between 23 and 41.


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Reoperation in case of stomastenosis after SRVG is necessary in order to prevent reflux esophagitis and in order to offer the patients a higher quality of life.

11. Esophago-gastroscopy After VBG - a Necessity or a Case-to-Case Procedure?

Husemann Bernhard, MD, Professor

Surgical Hospital of Dominikus-Krankenhaus, PO Box 29 07 51, D-40528 Diisseldorf, Germany

VBG significantly changes the physiology and motility of the distal esophagus and the lower esophageal sphincter (LES). Due to stasis and reflux there, one can expect physiological and pathological consequences, especially esophagitis-like lesions. Therefore we have established a postoperative follow-up, including endoscopy of the upper GI-tract (after 12 and 24 months) and X-ray by barium swallowing (3, 12 and 24 months postoperative). These diagnostic procedures were done by independent departments of our institution. The prospective clinical study was started in 1991; the mean follow-up time is 32 months- (min. 6, max. 54). The number of patients varied between 216 after 6, 139 after 24 and 12 after 54 months. The results were different. The rate of the typical esophagitis is less (5% after 6, 3% after 24 months); however we could see a high incidence of bacteriological and histological alterations (17% at 6 months, 12% at 24 months). Mostly there are mycotic ulcers. The rate correlates to pouch size and eating behaviour: a large pouch with a narrow outlet and frequent vomiting are very bad preconditions. Till now there was not seen a Barrett’s esophagus; however, the follow-up time could be too short. Endoscopy was necessary beside these facts in seven cases due to bleeding by pouchitis, where four patients suffered upon a stenosis of the outlet caused by an ulcer. In one patient we had to remove a bezoar.

We believe a smaller pouch and a better training of eating behaviour could prevent these dangerous complications.

12. Quality of Life Assessment of Morbidly Obese Patients Before and After Vertical Banded Gastroplasty: Preliminary Results of a Prospective Study

Wim G. Van Gemert, MD, Eddy M.M. Adang, MD, Jan-Willem M. Greve, MD, PhD, Peter B. Soeters, MD, PhD

University Hospital Maastricf, Department of Surgery, PO Box 5800, 6202 AZ Maastricht, The Netherlands

Introduction: The effect of Vertical Banded Gastro- plasty (VBG) on the Quality of Life (QoL) of morbidly obese patients is evaluated in a prospective longitudinal study by means of the Nottingham Health Profile (NHP) and a Visual Analogue Scale for global QoL assessment.

Methods: At present the l-year results of 15 patients treated with VBG are available for analysis. Compliance is 100%. Statistical analysis of weight loss is performed with the Student t-test. Pre- and postoperative QoL results are compared with the Wilcoxon Signed Ranks test and relations tested with the Spear- man rank correlation coefficient. Statistical significance was set at p < 0.05.

Results: The mean preoperative BMI was 47.0 (5.7) kg mPL and decreased to 30.0 (8.0) kg rnh2 postoperatively (p < 0.0001). The mean percentage excess weight decreased from 106.8 (25%) preoperatively to 31.9 (34.3%) postoperatively (p < O.OOOI). QoL improved significantly after VBG on the NHP-I dimen- sions mobility (p < O.OOOOl), energy (p < O.OOOS), pain (p < O.OOl), emotional reaction (p < 0.005) and further on the NHP-II (p < 0.00001) and the VAS (p < 0.0005). Significant correlations were found between postoperative QoL scores and weight loss (Y = - 0.60; p < O.Ol), complications (v = 0.63; p < 0.01) and revisional surgery (v = 0.68; p < 0.005).

Conclusion: VBG results in a satisfactory weight loss at 1 year postoperatively. Successful weight loss after VBG improves the QoL of morbidly obese patients dramatically. Complications and revisional surgery have an adverse effect on the postoperative QoL outcome.

13. Biliopancreatic Diversion For Treatment of Obesity: 1987-l 993 Experience

Roberto M. Tacchino, Marco Castagneto

Department of Surgery, Catholic University SH, Rome, Italy

This paper reports on the long-term fate, metabolic effects and complications of a 5-year follow-up of 160 obese patients (127 women) who underwent biliopancreatic diversion between 1987 and 1993. Mean preoperative weight and SD was 125 & 24.5 kg, body mass index (BMI) was 47.3 ? 7.9 kgm-’ and overweight 119.4 + 37.3%.

After the rapid initial weight loss, weight stabilization was obtained at 12-18 months. At 24 months


Abstracts

pt has had hyperacidity, 22 initial diarrhea that in two cases have been residual with a case of middle procti- tis; six pts have shown analytical steatorrhea, two pts light milk intolerance, three dumping syndrome in relationship with the kind of food, ten low levels of iron and eight initial deficit of zinc. Eight pts have had cholecistectomy. It is important to remark the return to normal in the type of alimentation and physicophysical recuperation by 90% of pts who had a weight loss correctly.

Conclusion: Scopinaro’s technique is a safe and well-tolerated, high comfort surgical procedure, giving a good control of weight in morbid and superobese patients.

the mean weight loss was 34.9 ? 8.5 kg (BMI = 29.7 If: 4.4 kg m -2, % overweight 36.7 I!I 21.5). The weight loss is stable at 60 months.

Early postoperative complications occurred in 23 patients (14%), two of which required reoperation. No complication was fatal. Thirty-four patients (21.2%) had 38 late complications requiring 38 reoperations (23.7%) 34 of which were incisional hernias, all repaired, and four specific complications (2.5%).

Twenty metabolic complications occurred in 12 (7.5%) patients the most frequent being sideropenic anemia (6.8%) and protein malnutrition (3.1%).

There has been a total of four deaths (one clearly unrelated, one unknown) in the series.

We conclude that BPD is a very effective, but potentially dangerous operation and should be re- garded as a tool for treatment of obesity by competent and dedicated teams who can provide an adequate follow-up and support to patients. 15. Biliopancreatic Diversion: Clinical

Experience

14. Treatment of Morbid Obesity with the Scopinaro Technique

Giacinto Nanni, Gianfranco Balduzzi, Renato Capoluongo, Paolo Demichelis, Andrea Scotti, Carlo Botta, Gianni Rosso

Division of General Surgery, S. Andrea Hospital, Vercelli,

A. Larrad-Jimhnez, B. Moreno-Esteban, L. Bernardos, G. Chamoso, I. Ramos, C. Sanchez-Cabezudo, B. Tallon

Hospital General Universitario ‘Gregovio Maratkh’, Madrid, Spain

Objective: To analyse the results obtained with Scopinaro’s technique in the treatment of morbid obesity.

Patients and methods: One hundred patients (pts) were studied after l-5 years from surgery, and overall results assessed. The technique employed consisted of a 4/S gastric resection (gastric pouch 150-200 cc) and gastrojejunostomy with section of the jejunum between 40 and 80 cm from ligament of Treitz according to whether the BMI was lower or higher than SO, and Roux-en-Y up to 50 cm from ileocecal valve.

Results: Mortality, two pts. Intra-abdominal abscess or peritonitis and splenectomy, 0 pt. Evisceration, one pt and late eventration 16 pts. Wound seroma, one pt; infection, one pt; lung infection, three pts and urinary infection five pts. Pulmonary embolism, two pts. Acute gastric dilatation, one pt. The initial weight decreased from 180 + 32 kg to 80 ? 14 kg, and the BMI from 56 ? 10 to 32 ? 5. Six patients did not achieve the expected weight loss and three put back lost weight with high-calorie liquids or alcohol ingestion (one pt). There were no marginal ulcers, hypoproteinemia, hyperoxaluria or hypocalcemia. One

Italy

Biliopancreatic diversion (BPD), by ad hoc stomach resection (AHS BPD) (Scopinaro, 1985), has been accepted as an effective surgical treatment of morbid obesity.

From 1 January 1992 to 31 March 1996, 52 patients (F/M: 47/S, mean age: 41.2 years, range 26-61) underwent AHS BPD. Mean pre-operative body- weight was 120.4 kg (range 94-160), with a mean Body Mass Index of 48.2 kgm-’ (range 38.5-64). Three of these patients were converted from a previous vertical banded gastroplasty to AHS BPD (one patient with stomach preservation). After at least 36 months follow-up, six patients underwent abdominal dermolipectomy (five associated with incisional hernia repair, one associated with thigh dermolipectomy). One patient died on the fifth postoperative day, because of massive pulmonary embolism. Mean postoperative hospital stay was 12 days (range: 11-30). Follow-up is currently in progress in all patients. Weight-loss of initial overweight was 78% in 22 patients with 224 months follow-up, with excellent long-term weight maintenance. Protein deficiency was the main specific complication, encountered in two patients (3.8%), mother and daughter, probably because of poor compliance to dietary regimen; chronic protein deficiency and hepatic failure in the older patient (59 years) required a take-down and restoration procedure 38 months after AHS BPD.


Abstracts

This clinical experience supports the effectiveness with significant side effects, and patients need careful and safety of AHS BPD, despite some criticism. This monitoring. procedure seems to be suitable to patients with severe obesity, elevated BMI, who poorly tolerate food intake restriction, but accept a long-term follow-up. Careful preoperative clinical assessment, selection of 17. The Duodenal Switch in Bariatric Surgery patients reliable in long-term follow-up (especially for dietary regimen in the post-operative months), is the Aniceto Baltasar, C. EscrivB, J. Mir6, C. Serra,

key of success with AHS BPD, in terms of weight loss R. Martinez, E. Marcote, L.A. Cipagauta

and reduction of specific metabolic complications. Hospital ‘Virgen de 10s Lirios’, Alcoy, Alicante, Spain

16. Bilio-pancreatic Diversion: Experience of 27 Cases with Emphasis on its Use as a Revisional Procedure For Failed Partitioning Surgery

James Ritchie, MB, BS, FRCS(ENG), FRACS

187 MacQuarie Street, Sydney 200, Australia

Twenty-seven cases of bilio-pancreatic diversion have been conducted since January 1993. Five have been conducted on patients who have undergone no previous operations for their morbid obesity. Most of these five have been patients in the super obese category, bilio-pancreatic diversion being advised in their cases in the belief that it was a more successful operation for weight loss for people of this type. The remaining twenty-two have been patients who have had previous partitioning procedures. Sixteen patients have been followed for 1 year, where the percentage of excess weight loss was 65%, at 2 years 54% of excess weight was achieved. Adverse side effects includes the passage of small renal calculi, disturbed LFTs, troublesome malodorous diarrhoea, and one case of abdominal adhesions which manifested themselves by obstruction in the early post-operative phase. Patients who have undergone the procedure and who have previously undergone partitioning surgery, deem it to be a highly successful procedure, with the ability to eat a normal meal, with no vomiting or reflux, being a very positive aspect. Most patients have managed to control the diarrhoea problem with bowel actions settling at between two and three per day at twelve months, and causing minimal inconvenience. Only one said that she felt it was a significant disadvantage from the social point of view. No patients so far have required TPN. Three have been treated with Viokase for low protein levels.

Conclusion: Bilio-pancreatic diversion can produce successful weight control where partitioning surgery has failed. It is however, a procedure that is associated

‘Mixed, combined or hybrid’ surgery as described by N. Scopinaro in 1976 is partially restrictive and malabsorptive surgery. Hess and Marceau added preservation of the pylorous, 4-5 cm of the duodenum and the term of ‘duodenal switch’ was accepted for this operation at the ASBS Meeting of Seattle, 1995.

The duodenum is divided with a linear cutter. At midgut the small bowel is divided. The distal alimentary loop is passed through the mesocolon mesentery and joined to the duodenum. The stomach is resected on the greater curvature by applying linear cutters. The b&o-pancreatic loop is anastomosed to the common

loop at 75 cm from the ileo-cecal valve. The magnitude of the operation is lessened by: (1)

good exposure through a bilateral subcostal incision; (2) use of linear staplers; (3) continuous running sutures for the anastomosis.

Results: Forty-two patients have been operated on. One patient died due to an oesophageal perforation. Operating time has been shortened to 130 min, postoperative stay to 5 days. Patients are eating all types of foods without restrictions. The mean EWL is 85% at 1 year. Only one patient requires medication for diarrhea. All are nomotensive and normoglycemic.

18. Gastric Emptying of Solids After the ‘Duodenal Switch’

Aniceto Baltasar, R. Martinez, R. Bou, J. Del Rio, M. Bengochea, F. Arlandis

Hospital ‘Virgen de 10s Lirios’, Alcoy, Alicante, Spain

Assessment of gastric emptying of solids (AGES) was done in 23 of 42 patients operated on for morbid obesity.

All patients have the ‘Duodenal Switch’, a modification of the Bilio-pancreatic Diversion described by N. Scopinaro. A partial parietal gastrectomy is done by excision with lineal staplers 90% of the stomach greater curvature. The lesser curvature, the antro- pyloric pump and 3-4 cm of the duodenum are pre- served. An end-to-end anastomosis is done to the


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20. Long-term Results of Biliopancreatic Diversion in Subjects With Prader-Willi Syndrome

Giuseppe Marinari, E. Gianetta, G. Adami, D. Friedman, E. Traverso, G. Camerini, G. Baschieri, B. Vitale, A. Simonelli, P. Gandolfo, N. Scopinaro

distal half of the measured small bowel and the biliopancreatic loop (proximal half of the small bowel) is joined end-to-side to the ileum at 75 cm from the ileocecal valve.

The AGES test is done by the intake of two capsules. These capsules are large and do not cross the pylorous until they break up by the gastric acid in 20 polivynyl fragments (ten oval and ten elongated ones of 6 mm). An endoscopy is carried out 2 h after the intake and the number of the retained fragments (markers) are evaluated. Biopsies are also taken in all patients from the gastric, pyloric, duodenal and small bowel mucosa.

Results: In all patients the fragments had passed into the distal small bowel. Only in two of them were there two and three fragments remaining in the stomach or duodenum. All biopsies were normal.

Conclusion: Gastric emptying of solids is normal after the duodenal switch operation for morbid obesity. There were no alterations on the mucosa lining of the stomach, duodenum or proximal ileum.

19. PBD + Transitory Gastroplasty Preserving Duodenal Bulb: 3 Year’s Experience

C. Vassal/o, L. Negri, A. Della Valle, M. Salvaneschi, C. Vegezzi, A. Griziotti, C. Dono, P. Mussi, M. G. Bausardo, P. Pietrobono

Interdisciplinary Centve of Obesity, Surgical Division, Stuadella’s Hospital, Stradella (PV), Italy

We have so far performed 512 bariatric surgery operations (312 restrictive procedures and 202 malabsorbi- tive procedures). In the last few years we introduced an evolution of BPD: BPD + transitory gastroplasty preserving duodenal bulb (53 cases). From a technical point of view the operation consists of BPD coupled with a gastroplasty which is transistory thanks to the use of the PDS band. In the last few cases, instead of a VBG (with the PDS band) in order to make the operation completely reversible without any suture on the stomach, we make a gastric pouch (with the PDS band) calibrated with the same tube for the lapband (L~cc~. We maintain completely the duodenal bulb (5 cm from the pylorus) making an end-to-side duodenal-ileal isoperistaltic anastomosis (with this kind of anastomosis we had only 2% of anastomotic ulcer). With this new procedure we have good results both for weight loss (similar to that of BPD-AHS) and for nutritional complications (we do not have any cases of ipoalbuminemia or diarrhea).

Complete results will be presented.

Department of Surgery, Ospedale S. Marfino, University of Genoa School of Medicine, Italy

The Prader-Willi syndrome (PWS), first described in 1965, is a congenital disorder characterized by neo- natal hypotonia, short stature, hypogonadism, mental retardation of mild to severe degree and compulsive hyperphagia with the development of early obesity. The co-morbidities related to obesity, such as respiratory failure, diabetes mellitus, atherosclerosis and its consequences, lead to a very short life expectancy of PWS subjects. Actually, they usually lie between 20 and 30 years of age. Food obsession and mental retardation inevitably cause the failure of any weight reduction program entailing the subjects cooperation, including surgical therapy by means of gastric restrictive procedures. Therefore, a surgical method based on reduction of energy intestinal absorption seems the most reasonable therapeutical approach to obesity in PWS patients. Eleven patients with PWS (seven M) were submitted to BPD between 1986 and 1993. Mean age was 20 (12-31) years, mean weight 121 (71-163) kg, mean excess weight 70 (34-111) kg, corresponding to 134% (67-216) of the ideal; mean follow-up is 65 months (max. 110). Mean body weight showed a reduction of 57% of the initial excess (IEW) at 2 years and then a progressive weight regain. The long-term weight maintenance appears disappointing, only two subjects having maintained a loss of more than 60% of their IEW by the fifth year. Prior to BPD three of the 11 patients had hypertension, two had type II diabetes mellitus and two had hypercholesterolemia. All complications had disappeared already 1 month after the operation and there was no relapse during the follow-up period. One patient had recurrent protein malnutrition and was submitted to elongation of the common limb 24 months after BPD, when IEW loss H&x5 ‘%4J%& pd&? z?uktihon JVz5 pevxa?PnA>7 normalized and the subject stabilized on a loss of about 65% of the IEW, which is still maintained by the sixth year. No other significant complication occurred during the postoperative observation period. In summary, contrary to what happens in the general morbidly obese population, BPD appears to cause a good weight loss in the PWS patients, but seems to be generally inadequate to guarantee long-term weight maintenance. Nevertheless, taking into account the


Absfracfs

rapidly fatal evolution of the disease and the fact that no other treatment is effective, prolonging the life of these unlucky young patients while improving its quality seems to justify the use of this surgical method.

21. Incisional Hernias Following Biliopancreatic Diversion (BPD)

Daniele Friedman, E. Traverso, G. Adami, E. Gianetta, G. Marinari, G. Baschieri, G. Camerini, B. Vitale, A. Simonelli, P. Gandolfo, N. Scopinaro

Department of Surgery, University of Genoa, School of Medicine, Italy

Incisional herniation remains a major problem for the general surgeon. Bariatric surgery is supposed to be a high risk surgery for wound dehiscence, incisional hernia and later incisional hernia due to the following conditions: overweight, increased risk of wound infection, nutritional status, midline incision.

From June 1984 to February 1996, 1712 patients submitted to ad hoc stomach (AHS) BPD with mean age of 37 years (7-69) and mean per cent excess weight of 119 (41-311), had a midline xipho-umbilical incision. All wounds were closed using synthetic, slowly absorbed filament placed in continuous or interrupted fashion with supporting surgical curset for 1 month. Ninety-nine per cent of the patients were reviewed at 1, 4, 12 months after operation and then yearly. At a mean follow-up of 71 months (1-140) 509 subjects (30%) developed incisional hernia, 185 (11%) of which were small umbilical ones (size < 3 cm). Four hundred and thirty-one (85% of the total) hernias appeared within 1 year after operation. The 63 (4%) total herniations (17 or 1% wound dehiscence) always occurred after massive wound infection and/or cough (from pre-existing chronic pneumopathy or postoperative pneumonia or heavy smoking).

The analysis of the data showed a highly statisti- cally significant association of some presumptive causal factors with the development of herniation: surgeon’s experience (p < 0.00025), age > 50 years (p < O.OOOl), overweight > 120% (p < 0.00025), pre-existing herniation and/or previous midline laparotomy (p < 0.00025). On the contrary no statisti- cally significant differences were found with regard to gender and technique of closure, neither significant association with hypoproteinemia. No aetiological factor is recognizable to explain later hernias. One possibility is observer error.

22. Imaging Findings of Small Bowel Obstruction Following Biliopancreatic Diversion

Ezio Gianeffa’, M. Bertolotto’, G. Marinari’, G. Adami’, D. Friedman’, E. Traverso’, G. Baschieri’, G. Camerini’, A. Simonelli’, N. Scoparino’

Departments of ‘Surgery and ‘Radiology, University of Genoa School of Medicine, Genoa, Italy

Biliopancreatic diversion essentially consists of a distal gastrectomy with long Roux-en-Y reconstruction where the GEA and the EEA are placed 250 and 50 cm proximal to the ileocecal valve (ICV), respectively. Therefore, the operation creates a substantial rearrangement of the anatomy of the digestive tract, the duodenum, the entire jejunum and the proximal ileum being excluded from the alimentary transit and flowed only by bile and pancreatic juice. Different patterns of small bowel obstruction can then occur, depending on which of the different intestinal limbs is affected.

Obstruction of the alimentary (from the GEA to the EEA) and common (from the EEA to the ICV) limbs is easily diagnosed because of the presence of symptoms, clinical signs, and radiological findings typical of bowel obstruction in intact subjects. On the contrary, due fo the absence of most usual symptoms and clinical signs, diagnosis is more difficult in case of obsfruction of the biliopancreatic limb (BPL), which, due to the longer limb length (in our series more than double that of the other two limbs considered together), is more frequent. The consequent delay of surgical treatment can lead to potentially lethal complications such as perforation and pancreatitis.

In case of obstruction of the BPL, plain abdominal film, as well as contrast X-ray, are always negative. The diagnosis is allowed by combining clinical and laboratory findings (persistent pain, high serum amylase and/or bilirubin) and US scan. This exam- ination, easily available, is able to show dilation of the excluded loops and/or of the duodenum, thus indicating emergency operation. CT, which in our opinion is not necessary, can detect the site of obstruction.

In our series of 2163 operated patients small bowel obstruction occurred in 1.1% of cases. Diagnosis was performed prior to operation in all cases observed in our department.

304 Obesity Surgery, 6, 19%

Abstracts

23. The Incidence of Protein Malnutrition (PM) After ‘Ad Hoc Stomach’ (AHS) BPD Can Be Minimized, While Preserving Good Weight Loss Results, By Elongating Alimentary Limb (AL) in Selected Patients

BPD is very long, but it leads to very good weight loss results with minimal complications.

Nicola Scopinaro, G. Adami, E. Gianetta, D. 24. The 20 Years Experience of the Center for Friedman, E. Traverso, G. Marinari, G. Camerini, the Surgical Treatment of Morbid Obesity at G. Baschieri, B. Vitale, P. Gandolfo, A. Simonelli Milan University

Department of Surgery, University of Genoa School of S.B. Doldi, G. Micheletto, E. Lattuada, M.A. Zappa,

Medicine, lfaly A. Favara, A. Restelli

Once the effectiveness of BPD was established, any further amelioration was aimed at reducing PM incidence. The fact that in the AHS PBD the mean gastric volume was very similar in the PM and non-PM operated patients showed that an excellent weight of stabilization (75% reduction of the initial excess weight, IEW), can be obtained while annulling any influence of stomach dimension on PM (13.3% with 6.5% recurrence). With the aim of further reducing PM incidence at the least price in terms of weight loss results, we decided to increase intestinal absorption in those patients who, due to their social-behavioral characteristics (protein content of customary food, capacity of modifying eating habit according to re- quirement, financial status), are at greater risk of PM. The majority of these patients, in our series, are included in the southern population. In fact, PM incidence was 8.6% with 4.0% recurrence in the patients from North vs 18.7% with 7.2% in those from South. From September 1992 to March 1996, all southern patients had AHS BPD with 3OOcm AL, unless their characteristics were strongly positive, while all north- ern patients had 200cm AL, unless their characteristics were strongly negative. In the 79 patients from North with a minimum follow-up of 2 years (10% with 300 cm AL), PM was totally absent, while in the 103 from South (35% with 200cm AL) the incidence

lsfifufo di Chirurgia Generale ed Oncolo Gia Chir. Cafte- dra Chir Gen I Univ. Milan0

Methods: Since 1974, 571 patients were operated for morbid obesity: 312 jejuno-ileal bypasses (JIB), 68 bilio-intestinal bypasses (BIB), 102 horizontal gastroplasties (HGP), 44 vertical gastroplasties (SRVGP), 45 adjustable silicone gastric bandings (ASGB): 25 by laparotomy and 20 laparoscopically (LASGB). Average follow-up is respectively 15, 5, 6, 3 and 1 years.

Results: The average weight loss was 37.2% (JIB), 38.7% (BIB), 30.9% (HGP), 34.3% (SRVGP) and 25.4% (ASGB). Morbidity was more frequent and more serious for JIB. Mortality was 1.2% (JIB), 3.1% (HGP) and 0 for the other procedures.

Conclusions: Our experience shows that BIB is still effective in very obese patients (BMI more than 50), in patients refusing dietary restrictions and in patients not suitable for gastric procedures for anatomic reasons or previous disease of the upper GI tract. LASGB is the gastric procedure of choice and it is the most easily accepted by the patients.

Every bariatric surgery procedure can achieve good results if the indications are correct and the follow-up is regular, strict and endless.

was 6.8% with 1.9% recurrence, with a general incidence of 3.8% and 1.1%. This excellent result, which 25. Long Versus Short Limb Roux-en-Y

means the near disappearance of revisional surgery, Procedures: Early Results in a Prospective

was paid for by a reduction of IEW per cent loss to Randomized Study of Metabolic, Nutritional

71. Particularly, the 200 cm AL operated patients and Anthropometric Outcomes

maintained 75%, while those with 300cm AL de- George S.M. Cowan, Jr, MD, Cynthia K. Buffington, creased to 66%. It is concluded that: (1) ethnic and PhD, Soichiro Uramatsu, MD, M. Lloyd Hiler, MD social-economic characteristics greatly influence the incidence of PM after BPD; (2) the frequency of this comnlication can be minimized, while still preserving

The Department of Surgery, College of Medicine, The University of Tennessee, Memphis, TN, USA

the best possible weight loss results, by adapting thi Patients who receive a long-limbed gastric bypass operation to the patient’s characteristics; (3) the criteria (GBP-X) may experience greater postoperative for these adaptations are peculiar for each particular weight loss than those who have a regular length population, and they can be learned only by basing Roux-en-Y limb gastric bypass (GBP-R). We hypo- on personal experience; (4) the learning curve with thesized that the potential malabsorptive differences


Absfracfs

between these two bariatric surgical procedures may also include changes in serum lipids, vitamin, mineral and other entities. By means of an institutional review board-approved randomized trial, we have been study- ing the differences between GBP-R and GBP-X in: (1) body weight, (2) vitamins (A, D, B,,), (3) minerals (zinc, magnesium, iron, ferritin), and (4) metabolic indices (i.e. glucose, insulin, cholesterol, triglyceride, lipoproteins) of 100 bariatric surgical patients. At the time of this abstract, we have followed changes in these indices at postoperative months 3 and 6 in 26 study subjects (15 GBP-X and 12 GBP-R), average age = 40 vs 41 years for the X-GBP and R-GBP groups, respectively (p = NS); average weight = 110 vs 111 kg (p = NS). The data show no significant differences between the two surgical procedures with regards to percentage reduction in body weight (16% for both groups at 3 months postoperative and a respective 22% and 24% for the GBP-X and GBP-R patients at the 6-months postoperative interval (p = NS), and no significant differences in weight-loss- induced improvement in postoperative levels of serum lipids (total, VLDL, LDL, IDL-cholesterol and triglyceride), fasting glucose or insulin. Neither surgical procedure effected post-operative levels of vitamin D, magnesium, or zinc but both procedures cause significant (p < 0.05) reduction in levels of vitamin A, vitamin B,,, ferritin and iron. Three and 6 months following surgery, GBP-X patients have a significantly (p < 0.05) greater reduction in ferritin levels and a trend towards lower postoperative levels of vitamin B,, than GBP-R subjects. These findings suggest that, up to 6 months postoperative, GBP-X causes greater nutritional complications than the GBP-R while pos- sessing no apparent advantage in regard to weight reduction or the metabolic entities measured.

26. Comparisons Between Vertical Banded Gastroplasty and Vertical Gastroplasty With Artificial Pseudopylorus For Morbid Obesity

Spiros T. Papavramidis, MD, lsaak I. Kessissoglou, MD, Konstantinos G. Sapalidis, MD, Leonidas K. Pavlidis, MD, Anastasios P. Aidonopoulos, MD

Surgical Dept IlI, Aristotelian University, AHEPA Hospi- tal, Thessaloniki, Macedonia, Greece

Forty-eight consecutive morbidly obese patients, 14 men and 34 women, with a mean age of 37 years (range 20-62 years) who underwent VBG were compared with 55 consecutive patients, 11 men and 44 women, with a mean age of 35 years (range 20-57

years) who were treated with VGAP between January 1988 and December 1991. The mean operating times ( & SD) were 95 k 10 min for VBG and 90 & 18 min for VGAP, and the mean hospital stay was 7.94 & 4.2 and 6.92 k 3.2 respectively. The early and late complication rate after VBG (18.4% and 28.9%) were significantly greater than that after VGAP (6% and 8%) (p < 0.05 and p < 0.01). The gastroplasty failure rate as well as the reoperation rate after VBG (8.3% and 22.7%) were also significantly greater than that after VGAP (2% and 2%) (p < 0.001 and p < 0.001). There was a single postoperative death due to a necrotizing pancreatitis in the VBG group and a single death due to massive pulmonary embolism in the VGAP group.

Concerning the body weight loss, the percentage excess weight loss (? SD) in the lst, dnd, 3rd, 4th and 5th year after operation was 68 & 12, 74 + 10, 76 & 9, 74 & 10 and 69 ? 9 for the VBG group and 71 k 12, 89 ? 9, 80 ?Y 11, 81 ? 10 and 79 ? 9 for the VGAP group. The postoperative changes ( ? SD) in mean BMI at the same time were 35 & 7, 29 & 6, 29 2 4, 32 ? 7 and 33 & 4 for the VBG group and 34 ? 7,28 ? 3,28 ? 3,28 !Z 4 and 28 ? 3 for the VGAP group.

In conclusion, VGAP has significant advantages in terms of complications, gastroplasty failure and reoperations while the results in excess body weight loss were slightly better than that of VBG.

27. The Adjustable Silastic Band Versus the Vertical Banded Gastroplasty: 5Year Outcomes

S. Ross fox, MD, Katherine Fox, RN, MPH, Ki Hyun Oh, MD

Private Practice, Seattle/Tacoma, Washington, USA

Five-year follow-up outcomes of a prospective study comparing the Adjustable Silastic Gastric Band (Bio- enteric@) with Vertical Banded Gastroplasty are described. Comparison of weight loss, satisfaction, compliance, complications and technical parameters are made. Sample consists of 33 laparotomized ASGB and 81 VBG patients having surgery over a 9-month period. None had previous bariatric procedure. Demo- grahics are similar. Lost-to-follow-up are 24% ASGB, 51% VBG. Methods include retrospective/concurrent chart review and telephone interview. Analyses include central tendency, standard deviation, variance and significance. Results indicate average per cent excess weight lost at 24 months (65%) varied during


Abstracts

Table 1. Development of NIDDM in operated and non-operated

groups the 36 and 48 month periods, then converged at 60 months (64%). Twelve-and-a-half per cent of the ASGB and 10% of VBGs were revised to gastric bypass. One ASGB death occurred unrelated to surgery. VBG complications were more severe. Failure was most commonly due to non-compliance with dietary regime (both groups). The ASGB patients were more compliant with follow-up and supplements. Satisfaction was similar, however dissatisfaction was greater in ASGBs, probably due to early mechanical difficulties which have been subsequently corrected as well as the learning curve involved with a new type of gastric banding procedure. ASGB and VBG for selected patients can result in successful weight loss over an extended period. ASGB is safer. It is reasonable to attempt weight loss via banding as a first stage procedure, if patients are screened for appropri- ateness, and understand the limitaitons and potential for revision.

28. Gastric Bypass Surgery Prevents the Development of Overt NIDDM in Patients With ‘Occult’ NIDDM

Stu Long, BS, Melvin S. Swanson, PhD, Kenneth G. MacDonald, Jr, MD, Brenda Brown, RRA, Patricia Morris, RN, Walter J. Pories, MD

East Carolina University Department of Surgery, Green- ville, North Carolina

In this study, we examine whether the gastric bypass operation (GB) has any effect on preventing the development of overt Non-Insulin Dependent Dia- betes Mellitus (NIDDM) [fasting blood glucose (FBS) >14Omgdl-’ or on oral hypoglycemics or insulin] in patients with ‘occult’ NIDDM (FBS < 140 mg dl-l and blood glucose 2 200 mg dl- ’ at 2 h post glucose loading during a 75 g oral glucose tolerance test).

Methods: The effects of surgery versus non-operative therapy were compared in 61 clinically morbid obese patients (> 4.5 kg excess body weight) with ‘occult’ NIDDM who were referred to the ECU School of Medicine for bariatric surgery from 28 April 1980 to 13 April 1994. Of these, 50 patients had the GB while 11 did not undergo the procedure. Individuals denied the GB for medical reasons were excluded from this study.

Results: Of the 11 ‘occult’ NIDDM in the non- operated group, 6 (55%) developed overt NIDDM compared to none from the group who had the procedure (see Table 1).

Non-op DP BP-value

n 11 50 ns

Age (years) 42.8 40.8 ns

FBS (mg dl-‘) 123.5 122.7 ns

Weight (lb) 310.5 314.0 ns

Follow-up (years) 8.0 10.2 ns

Developed overt NIDDM 6 0 0.0001

Conclusion: These data support the thesis that the GB prevents the development of overt NIDDM in patients diagnosed with ‘occult’ NIDDM.

29. Infectious Potential of the By-passed Stomach in Gastric Bypass Patients

Soichiro Uramatsu, MD, George S.M. Cowan, Jr, MD, M. Lloyd Hiler, MD, Cynthia K. Buffington, PhD

The Department of Surgery, College of Medicine, The University of Tennessee, Memphis, TN, USA

The blind-ended, by-passed stomach logically ought to be sterile 18 months or longer after a gastric bypass procedure (GBP). Were this not the case, micro-organisms in this location could be potential contaminants at re-operative bariatric surgery involv- ing the distal stomach as well as contribute to possible induction of gastric dysplasia or blind loop syndrome. We therefore cultured intra-luminal fluid obtained from the distal stomachs of 30 postoperative gastric bypass patients who were admitted for elective ventral herniorrhaphy, abdominoplasty or other intra-abdominal elective procedures at least 18 months after their GBP. During the surgery, we aspirated fluid from the by-passed stomach with a no. 14 Angiocath, submit- ting it for aerobic and anaerobic cultures. Through the needle puncture wound, we obtained a gastric mu- cosal biopsy on a subset of 19 of these patients, 16 of whom had gastritis. Of the 30 patients, 21 had cultures which were positive for aerobes and two for anaer- obes. Seventeen of these aerobic cultures were positive for yeast, nine for other microorganisms, and five for both yeast and other organisms. We conclude that, 18 or more months following GBP, 70% of the bypassed stomachs contain microorganisms. This is of concern for reoperative surgery and possible postoperative infectious complications. Since such a high percentage of gastric cultures produced yeast, an antifungal agent might be advantageously employed prophylactically in each patient whose bypassed stomach may be opened during surgery.


Abstracts

30. Psychological Aspects in Patients with LASGB

L. Maroquin, E. Chelala, G.B. Cadikre

Department of G.I. Swgeuy, CHU Saint-Pierre, Brussels, Belgium

Aim of the study and methods: Preoperative interview and personality testing, including a self esteem scale (DEBQ) and two projective tests (Rorschach and TAT), allow us to: (I) preoperatively document the personality structure and the behavior of the morbidly obese patient, (2) detect any possible psychological contraindication, (3) reveal the importance of postoperative psychological follow up.

Results: Personality characteristics: (1) impaired reasoning capacity, (2) poor perception of one’s own limits, poor interiorization of body image and of time frame, hence loss of identity and dependency on others, (3) ambivalent parental relationship, (4) need to resemble a model and to idealize this model.

About behavioral characteristics: (1) patients are impulsive, (2) patients view their body as a tool to substantiate tensions related to their cultural differences, (3) violation of rules by overeating. Our analysis showed that all these personality and behavioral characteristics are very close to a borderline personality structure. Personality and behavior after the procedure: (1) improved reasoning and ability to link events together, (2) reintroduction of the ‘time’ notion because of the rigorous schedule for the meals, placement of the Lap Band creates a psychological change with regained perception of internal limits, (3) reduced impulsivity, (4) the Lap Band be- haves like a brake, (5) the operation indirectly limits their frustration, (6) the patients are no longer passive and submissive and they become active, (7) interaction between the band, the loss of weight and their consciousness.

Conclusion: The role of the band and the psychological surroundings are in interaction. Unlike people without a Lap Band, for whom desire or stress are immediately geared towards food ingestion, the patients with the Lap Band build in a time for reflection. Tension, however, persists despite the reflection. Psychotherapy or psychological aid should therefore be oriented towards dealing with this psychological tension. If the patient does not learn to implement this reflection time, food ingestion will resume in the long run and efficiency of the gastroplasty will be jeopardized.

31. Prediction of Weight Loss After Restrictive Procedures

Roberto M. Tacchino, Marco Castagneto

Department of Surgery Catholic University SH, Rome, Italy

No medical treatment for obesity reliably sustains weight loss, perhaps because metabolic processes resist the maintenance of the altered body weight. It has been demonstrated that maintenance of both a reduced or elevated body weight is associated with compensatory changes in energy expenditure, which oppose the maintenance of a body weight that is different from the usual weight. These compensatory changes may account for the poor long-term efficacy of treatments for obesity. We have applied a mathe- matical model of body weight and energy balance to the case of restrictive gastric procedures to evaluate the agreement between predicted and observed results. The mechanism of action of gastric restriction is through reduction of caloric intake, thus, if the metabolic consequences are similar to those of dieting, the model would predict the results and help in the selection of patients.

EL

BO

WS 910 t

+--t-+--t-+---i--1 xl 40 60 80 ml lzl 140 160 180 ax 2a 24 xi3 290 x0

Ind EBwb

Figure 1. Body weight and energy balance

The agreement between predicted and observed values in both situations confirms validity of the model and the presence, after gastric restrictive surgery, of the same metabolic modifications following dieting. The application of this model to predicting results of restrictive procedures would help in select- ing the patients who would benefit from surgery particularly when the presence of alterations of body composition or energy expenditure predisposing to failure could be screened preoperatively. Surgeons


Absfracfs

should be aware that, for obese patients, achievement of weight loss may be accompanied by metabolic alterations that make it difficult to maintain the lower weight even in the presence of a mechanically intact restrictive mechanism.

32. Complications and Sequela of Jejunoileal Bypass in 64 Patients Followed-up For More Than 15 Years

P. Forestieri, L. Meucci, M. De Luca, C. Chiacchio

Department of Surgery, University ‘Federico II’ of Naples, Italy

Introduction: The complications of jejunoileal bypass are very frequent and often severe. Therefore, a careful review of the surgery approach started in the last few years. However, many discrepancies have been reported in the experience of American and European authors.

Materials and methods: We here report 64 cases followed-up for at least 1.5 years. Patients underwent a termino-lateral jejunoileal bypass with double anti- reflux valvular system. In each patient an intestinal tract of variable length remained functional. It was generally 7.5% of total jejune plus 2.5% of ileum.

Results: We observed a progressive reduction of diarrhoea. In most patients the number of episodes decreased from 10-20 per day immediately after the surgery, 4-6 per day after 6 months and 2-4 within the first year. Eventually, 1-3 episodes per day were normally reported. Early complications were usually local and often developed as a consequence of serious diarrhoea. Most frequently wound infectin occurred (lo.g%j. Useful manoeuvers to reduce this complication were subcutaneous retraction, subcutaneous suturless, antibiotic prophylaxis and multiple drainage. As sequela of severe diarrhoea we observed serious electro- lytic deficits (3.1%) that required adequate replacement treatments, and anorectal pathologies (25%) such as hemorrhoids, rhagades, fistula and prolaps. Early general complications we often reported were pulmonary emboli and myocardial infarction (1.5%). Malabsorp- tion represents a subsequent complication. We found only six cases of bypass entheritis: two abdominal syndromes, two polyarticular syndromes and two cutaneous syndromes. As far as hepatic failure is concerned all patients were followed-up by regular labs and biopsy. After 3 years from the surgery we reported: massive steatosis (six cases); incomplete sectal cirrhosis + massive steatosis (one case); micro- nodular active cirrhosis (one case); massive steatosis

+ granulomas + fibrosis and active phlogosis (one case); intact lobular structure + modest focal or centrolobular steatosis + fibrosis and inflammation of few portal area (50 cases). Three cases of death were due to hepatic failure. Further delayed complications were: incisional haernia (11 cases); vitamin deficits (two cases); ipocalcemic tetanus (one case); excessive weight loss (one case); alopecia (one case); zinc and copper deficits (one case); urinary lithiasis (two cases); bile tract calculosis (one case); lack of weight loss (two cases). We performed three reversions (two due to hepatic failure and one for excessive weight loss) plus one revision (lack of weight loss).

Conclusions: Although jejunoileal bypass has many serious complications it represents an effective surgical approach for severe obesity. In fact if patients are correctly followed-up and carefully observe therapeu- tic prescriptions these complications can be prevented. Furthermore, all complications can be easily treated by reversion. From a technical point of view this bypass is certainly the easiest surgical approach and, most importantly, it can be easily and completely reverted. The frequency of complications can be significantly decreased by a proper selection of the patients, a careful follow-up, and a strict diet. To conclude, though the surgery is technically simple a good and expert follow-up is essential to succeed and to prevent serious as well as numerous complications.

33. Reducing Early Technical Complications in Gastric Bypass Surgery

Rafael F. Capella, MD, Joseph F. Capella, MD

Private Practice, Pascack Valley Hospital, Westwood, NJ, Good Samaritan Hospital, Suffern NY, and St Luke’s- Roosevelt Hospital Center, New York, NY, USA

Introduction: The incidence of complications following gastric bypass surgery has decreased dramatically over the last 30 years. Nevertheless, significant morbidity and mortality is still associated with this procedure.

Methods: We reviewed the literature and compared our series of 840 primary cases of vertical banded gastroplasty-Roux-en-Y gastric bypass (VBG-RGB), a form of gastric bypass, for the incidence of gastrointestinal leaks, obstruction of the excluded segment of gastrointestinal tract and death.

Results: There were no gastrointestinal leaks, ob- structions of the excluded segment of gastrointestinal tract, or deaths in our series of 840 patients. Our series compares favorably with the incidence of these major complications reported in the literature.

Obestty Surgery, 6, 1996 309

Abstracts

Conclusions: We feel that the safety of VBG-RGB results from, (1) the anatomic location of the gastric pouch, (2) the type of stapling device used in its construction, (3) a pouch outlet restricted by a pros- thetic band rather than a narrow anastomosis and (4) the construction of a retrocolic, retrogastric Roux- en-Y gastrojejunal anastomosis.

34. Stoma1 Ulcer After Gastric Bypass

Lloyd D. MacLean, MD, Barbara M. Rhode, PDt, MSc(Nutr), A. Peter H. McLean, MD

McGill University, Montreal, Quebec, Canada

Among 499 patients who underwent Roux-en-Y gastric bypass from January 1988 to December 1995, 28 developed a stoma1 ulcer between 1 month and 6 years following operation. Stimulated acid output from the gastric pouch was measured in 11 of the patients with stoma1 ulcer, 26 control patients with an intact staple line, and in 14 patients with a perforated staple line without ulcer. The acid output (mean + SD) was 19.56 ? 9.67mEqhP’ in the patients with ulcer, 6.52 ? 9.92mEqh-l in the patients with a fistula only and 0.75 + 0.20 mEq h-’ in the controls with an intact staple line. Significant differences were: Ulcer vs Fistula p < 0.001; Ulcer vs Controls p < 0.001; and Fistulas vs Controls p < 0.05. With an indwelling pH meter the ulcer patients had a significantly greater duration of time with pH < 2 (mean 2 SD)

49.33 k 27.9% of time vs controls 10.61 2 15.18%. Acid production and pH in the gastric pouch was significantly improved after closure of the fistula in the six patients operated upon and subsequently studied (acid production p = 0.0021 and pH p = 0.042). Of 123 patients with gastric bypass in continuity 16 patients developed a perforated staple line and stoma1 ulcer that was corrected by isolated gastric bypass in nine; by reversal in six; and by subtotal gastrectomy in one. In 12 of 376 patients with isolated gastric bypass, multiple gastric operations (three or more) predisposed to perforation in ten. Isolated gastric bypass alone was followed by perforation and ulcer in two patients, one of whom had severe abdominal infection. In conclusion, isolated gastric bypass decreases the incidence of gastro-gastric fistula and stoma1 ulcer but further measures are necessary in patients who have had three or more previous attempts at gastric limiting surgery. No stoma1 ulcers occurred without a communication between the gastric pouch and the stomach. High acid levels in the gastric pouch were associated with stoma1 ulcer.

35. iron Deficiency and Anemia After Roux-en- Y Gastric Bypass: a Prospective Longitudinal Outcome Study

R.E. Et-o/in, MD, J.H. Gorman, MD, R.C. Gorman, MD, A.J. Petschenik, MD, L.J. Bradley, MS, RD, H.A. Kenler, PhD, R.P. Cody, PhD

Robert Wood Johnson Medical School, New Brunswick, NJ USA

We have followed hematologic parameters in 348 patients who had RYGB during a IO-year period. Mean follow up was 42 ? 10 months. The purpose of this study was to learn how these deficiencies respond to postoperative iron supplements and whether the risk of deficiency gradually decreases over time. Iron deficiency was recognized in 155 patients (47%); 177 patients (54%) developed anemia. Microcytic, hypochromic indices were found in most anemic patients. No patient had macrocytic anemia. Hgb and Hct were significantly decreased vs preoperative levels at all postoperative intervals. Moreover, at each successive interval Hgb and Hct were decreased significantly vs the prior interval through 5 years. After 5 years Hgb and Hct levels were increased relative to values obtained betwen 3 and 5 years postoperatively. Iron levels remained relatively stable postoperatively. Iron deficiency was noted in 51% of female vs 22% of male patients (p < 0.001). There was no significant gender difference in the incidence of anemia. Low iron levels were significantly less common in women who had hysterectomy (TAH) vs those who did not. However, low Hgb levels did not correlate with TAH suggesting that post-RYGB anemia in some women has causes other than iron deficiency. T k’ g a m multivitamins did not prevent iron deficiency. Oral iron supplements corrected deficiencies in about 50% of cases. These results show that anemia is a potentially serious problem after RYGB. Mechanisms involoved in evolution of anemia after RYGB must be indentified so that more effective strategies for prophylaxis can be developed.

36. Czech Approach in Integrated Management of Obesity

V. Hainer, MD, PhD’, M. KuneSov&, MD’, M. Fried, MD, PhD’, J. ParizkovB, MD, PhD, DSc’

Obesity Unit, ‘Fourth Department of Medicine, ‘First Department of Surgery, Charles University, General Faculty Hospital, Prague, Czech Republic

3 10 Obesity surgery, 6, 1996

Abstracts

team has performed obesity surgery since July 1992 in cooperation with the psychiatrists. We performed 114 Kuzmak’s operations, 101 of which by laparotomy and recently in 13 in laparoscopy, having a BMI between 36.5 and 63.3 kgm-‘. Seventy-one of these patients had a minimum l-year follow-up, yielding an average weight loss of 35.9 kg (48.3%); 33 of these last patients reported a 43.7 kg (63.7%) weight loss on a 2-year follow-up, while 14 patients on a 3-year follow-up showed a 48.7 kg (68.9%) weight loss. The main complications due to the band were the following: a concentric gastric pocket dilatation in seven patients (7.9%) treated by calibration and an excentric dilatation which required a new operation in five patients (5.7%); gastric wall erosions (three cases, 3.4%) with band penetrating into the gastric walls. Oesophageal reflux (five patients, 5.7%) and LES and esophageal body hypotone (three patients, 3.4%) are still being evaluated if band removal should be required. This experience confirmed our opinion to integrate a psychiatric support to these patients along with psychotherapeutic meetings, even in groups, which we hope will allow these patients to reach and maintain the results obtained by surgery.

Obesity represents a substantial health problem linked to numerous chronic diseases that lead to premature disability and mortality. Morbid obesity results in a 12-fold increase in mortality in young men when compared to lean individuals. According to studies carried out in western countries current economic costs of obesity represent 5-S% of all direct health costs. We have confirmed that an effective treatment of obesity results in a substantial decrease in expendi- tures associated with pharmacotherapy of hypertension, diabetes, hyperlipidemia and osteoarthritis. WHO International Obesity Task Force recommended to engage national governments and organisations to promote a new approach in integrated prevention and management of obesity. The Czech Society for the Study of Obesity has initiated a comprehensive weight management program carried out in outpatient obesity clinics, weight reduction clubs and in obesity units attached to the university hospitals. This program has established new realistic goals in obesity management in accordance with recent experience showing a beneficial health effect of modest weight loss. Postgraduate courses for physicians, training for counsellors of weight reduction clubs as well as regular seminars focused on the case reports have been included into the program. Intensive collaboration between physicians from the obesity unit and surgeons involved in bariatric surgery is required in order to assure an appropriate management in severely obese individuals.

37. ASGB and Psychotherapy: a New Integrated Approach

Marcel/o Lucchese, MD, Albert0 Duranti, MD, Fabrizio Alessio, MD, Francesco Venneri, MD, D. Borrelli, MD, PhD

Department of General and Vascular Surgery, Careggi Hospifal, Florence, Italy

The solution to this severe psychic, rather than physical, disease surely requires a surgical approach, but in order to assure a long-term success, we are firmly convinced that psychotherapeutic approach should be allowed so as to change the patients’ behaviour towards nutritional habits. Surgery is to be considered as an ‘obliged step’ in the treatment of severe obesity and must therefore have precise requisites: a very low surgical trauma, absolute reversability, an acceptable weight loss and a good life-quality. Adjustable gastric banding has proved to meet these requisites in our experience, mainly today, through laparoscopy. Our

38. Pre- and Postoperative Nutritional Managements For Gastric Restrictive Surgery

lsao Kawamura, MD, PhD, Masaaki Kodama, MD, Yoichi Sakuma, MD, Satoru Takaishi, MD, Hajime Tanaka, MD, Koji Saito, MD

]A Tochigi Marronnier Medical Center, Tochigi, ]apan

We have been adopting gastric restrictive procedures with vertical banded gastroplasty and K-gastroplasty for morbid obesity patients. To achieve the success rate elevated of the operation, pre- and postoperative nutritional management is important. As a preoperative nutritional management, we have routinely been administrating protein sparing modified fast for 2 weeks, for the purpose of reducing operative risk which is generally extremely high among morbidly obese patients. By this administration we have obtained 7-8 kg of their body weight reduction as well as improvements of their obesity related complications. As a postoperative nutritional management, behavior modification of the food-intake has been associated. Because of the very small gastric pouch, their original food-intake patterns have to be changed postoperatively. I would like to show our actual pre- and postoperative nutritional managements.

Obesity Surgery, 6, 1996 3 11

Abstracts

39. Adjuvant Weight Loss Chemotherapy - a Case Report

Andrew C. Jamieson, BSc, FRACS, FRCS

in the complex treatment of obesity as one of its main programs. Our clients represent a broad spectrum ranging from simple overweight condition, to cases of morbid obesity that represent a serious health prob-

Department of General Surgery, Box Hill Hospital, Box lem. These patients make up IO-15% of all our clients Hill, Australia suffering from obesity. From our viewpoint, the neces-

A 36-year-old woman underwent vertical gastroplasty for morbid obesity (see: Jamieson, A.C. Why the operation I prefer is the modified Long vertical gastroplasty. Obes Surg 1993; 3: 297-301). She weighed 109 kg (BMI 39.1 kg m-‘) and surgery was uncompli- cated. After 89 days she had lost only 11 kg and had been complaining since operation of hunger soon after meals. She was able to eat any type of food, had no regurgitation and was able to eat much larger volumes of food than expected. Gastroscopy revealed an intact staple line and stoma. She was prescribed oral propantheline and immediately noticed an improvement in satiety, a reduction in capacity for food and some difficulty in tolerance of meat or chicken. This change has been maintained and weight loss has been very good (Figure 1).

kg t

l

l l

e commenced

Days post operation

sary pre-condition for successful treatment is the introduction of a long-term weight reduction program, when the planned weight reduction represents a maxi- mum of 4 kg monthly. For cases of relapse obesity, when the conservative treatment procedures have failed and the BMI index is 40 or more, we consider it as fully indicated to begin the complex treatment with bandage stomach. The operations are performed for our Center by Mr Fried, MD at the First Surgery Clinic. SAGA represents for our patients an important progress in treatment, particularly with respect to the prevention of known complications connected with bandage of stomach. The main problem is the price, because this operation is not covered by the standard health insurance provided by our insurance companies.

41. The Long-Term Effects of Gastric Pacing on an Obese Young Woman

Valerio Cigaina, MD, Alfred0 Saggioro, MD, Vincenzo Pezzangora, MD

Department of Gasfroenferology and First Department of General Surgery, (Umberto First) Mestre, 30174 Venezia- Mestre, Italy

Background: Following the Ninth International Con- Figure 1. Scatter of kg lost by time after surgery in 37 gresson Obesity Surgery held in Stockholm, Sweden, other patients between 108 and 110 kg at operation and weight loss curve of subject before and after pro-

in September 1995 at which our group presented the

pantheline. results of the paper entitled, ‘The Long-Term Effects of Gastric Pacing to Reduce Feed Intake on Swine’,

Propantheline, an antispasmodic and parasympatho- mimetic drug may be a useful adjunct to gastroplasty where there appears to be poor satiety and weight loss due to rapid transit of food through the stoma.

we performed the initial human experimental gastric implant.

Methods: A 23-year-old obese white female, weighing 149 kg (BMI OF 52.5) had an antral gastric pace- maker implanted on 8 December 1995.

Results: Since implantation, the patient has lost 51 kg equivalent to better than 50% of her excess weight. During implantation no specific dietary limitations were instituted with daily intake consisting of three meals without limitations in quantity or quality

40. Our Experience With the Treatment of Morbid Obesity

Ren& VlasBk, MD of sustenance. Only sweet drinks- were prohibited.

Center of Preventive Medicine, Prague

Since its foundation in 1993 as a private organisation, the Center of Preventive Medicine has been engaged

The patient tolerated pacing well without complication. After initiating gastric stimulation, the patient’s bowel behavior was noted to increase from an average of 0.8 bowel movements per day prior to pacing to

3 12 Obesity Surgery, 6, 1996

two bowel movements per day of solid stool. We reported an increasing level of endogenous insulin during the first 2 months of antral electrical stimulation without reactive hypoglycemia, with the insuline- mic and glycemic curves under oral glucose intake normalizing. Prior to stimulation, the SGPT was elevated. During the first few months after intiating pacing, we also observed an elevation in SGOT; however, by December 1995 both the SGPT and SGOT normalized. Gallbladder sludging diagnosed with ultrasound prior to pacing evolved into a mono- lithiasis state (diameter of 2.5 cm). Gastroscopy performed also demonstrated larger quantity of gastric juice than normal, yet no lesions of the gastric mucosa evolved; some caudocranial peristaltic movements were detectable. Impaired gastric peristalsis was also confirmed with Gastrografin meal testing with the stomach abruptly discharging all 125 ml of the Gastrografin approximately 50 min after ingestion.

Conclusion: To explain this clinical result regarding long-term gastric pacing, we suppose: (1) that antral gastric pacing induces a local electrical phenomenon similar to that of a cardiac re-entry mechanism where localized repetitive firing of the ventricular myocells is seen; (2) that this specific re-entry circuit is coupled with a gastric tachyrrhythmia where the tachyrrhythmia leads impaired gastric peristalsis and prolonged gastric transit. We do not exclude, however, the possibility of a neuro-mediator (octeotride?) increted by the myenteric plexus of an electrically stimulated gastric antrum potentially acting as a false messenger in producing central and visceral neuromediated effects.

42. Prevention of Incisional Hernias in Bariatric Surgery

Giorgio Gaggiotti, MD, Roberto Ghiselli, MD, Luigi Goffi, MD, Paolo Orlandoni, MD, Robin Chan, MD, G. Franc0 Boccoli, MD, Vittorio Saba, MD

Semeiotica Ckirurgica, Universitiz degli Studi di Ancona, INR CA, Italy

Two different techniques of abdominal wound closure in Bariatric Surgery were studied to determine the efficacy in preventing incisional hernias.

Materials and methods: The study included two groups. Grotip A: 32 patients (14 F, 16 M), age 45 (27-56), BMI 48.7 (40.2-63.5), EBW (%) 114 (70.1- 179); 30 underwent Biliopancreatic Diversion equal limbs (BPD), two underwent Silastic Vertical Ring

Abstracts

Gastroplasty (SVRG). Group B: 13 patients (11 F, two M), age 36.6 (25-62), BMI 45.9 (40-54.8), EBW (%) 101.5 (76.7-129.4); eight patients underwent BPD, five patients SVRG. In all patients laparotomy was performed through an upper abdominal midline incision. The anterior sheaths of the rectus muscles were incised on each side 1 cm laterally from the linea alba, while the posterior sheath and the peritoneum were incised through the midline. The abdominal wound closure was performed as follows: the peritoneum was sutured, together with the posterior sheath of the rectus muscles, using a continuous non-absorbable monofilament suture. In the first group a piece of 20cm wide polypropylene mesh (Marlex) was placed on the posterior rectus sheath using interrupted sutures; the anterior rectus sheath was sutured using non absorbable monofilament interrupted sutures. In the second group the same procedure was performed but no mesh was used. In all patients antibiotic prophylaxis was used in the first 3 postoperative days. Subcutaneous suction drainage was maintained for 3 days.

Results: No immediate postoperative septic wound complications were observed. The overall follow-up was 13.3 months. In the first group, after a mean follow-up of 16 months, BMI was 34.7 (24.1-41.7), EBW (%) 52.8 (O-94.8), and one patient presented incisional hernia. No incisional hernias were found in group B after a mean follow-up of 10.6 months BMI 32.5 (24.3-43.9), EBW (%) 42.7 (10.9-81.3).

Conclusions: The very low incidence of complications and the outcome on preventing incisional hernia encourage the use of presented procedures, even though they are more time consuming and more expensive (group A). A more extensive follow-up is necessary to confirm these results.

43. Upgrading Laparoscopic Vertical Banded Gastroplasty (VHWS-VHS Video Film of 10 min)

J.L. A//6, M. Poortmans

CHU Tivoli, La LouviBre, Belgium

Having introduced 3 years ago the first laparoscopic approach for Vertical Banded Gastroplasty (LVBG) and a first group of 120 consecutive cases having shown results at least equal to those of open surgery, a new protocol is described in a 10min video film, in order to ensure total reproductibility of the neo-gastric pouch specifications (volume, output calibration . .) and to increase surgical feasibility.

The main features of the new procedure are:


Abstracts

- a limited d-ports access avoiding the deleterious and unaesthetic 33-mm umbilical one;

- the creation of a 15-20 ml small pouch by stand- ardization of the neo-gastric length;

- the calibration of the neo-gastric pouch output by use of a new-designed calibration clamp combined with a perforating device in order to guide the fenestration step of the procedure;

- the use of thinner instrumentation and better axis for the circular stapling.

All of these modifications result in a new-look procedure offering calibrated LVBG and combining technical security and functional reproductibility.

44. Reflux Oesophagitis and Hiatal Hernia Treated By ‘Athens Method’ in Morbidly Obese Patients (MOP). Indications for Application in Normal Weight Patients

A.A. Anagnosfides, MD, PhD, Caragiorgas, MD

Gastro-Unit, ‘Hygeia’ Hospital, Athens, Hellas

Gastric reflux and hiatal hernia are very common in MOP. The basis is increased pressure and disrupted nesophangeal fundal angle.

We observed that MOP with gastric reflux, oesophagitis and hiatal hernia were cured after the application of ‘Athens Method’.

The effect of ‘Athens Method was studied in 40 MOP with gastric reflux, oesophagitis and hiatal hernia proven clinically, radiologically and endoscopi- tally. A questionnaire was filled after the operation and monthly for 24 months. Radiological studies were done at 3, 6, 12, 18, 24 months and Gastroscopy was performed at 6, 12, 24 months.

1. Gastric Reflux Symptoms stopped immediately after the application of the band.

2. No Gastric Reflux into pouch was observed in all radiological examinations.

3. No sign of oesophagitis was found in endoscopy.

4. Symptoms return in four dislocations of the band (> 3 cm) and disappear again with correction.

5. There were no symptoms or regurgitation when the band was deflated for a few hours.

6. No symptoms or regurgitation were detected in MOP that sustain normal weight.

The application of ‘Athens Band in the fundus creates

a very sharp angle between fundic pouch-stomach and it seems to increase the pressure of the pouch cephalicaly to caudally that does not allow the regurgitation of acidic gastric fluids. The few number of parietal cells contained in the small fundic pouch ( < 80 cmz) cannot alter the pH and cause damage to oesophagus.

The simple procedure of ‘Athens Method, the low complication rate, the advantage of laparoscopic application and the high success rate together with the advantage of losing weight makes the method ideal for the treatment of gastric reflux and oesophagitis in MOP and encouraging for the application in non-obese patients, since the mechanism of gastric reflux is the same in both groups.

45. Gastric Banding For Morbid Obesity in 300 Consecutive Patients

7. Suchp, M. BernardovA

Department of Surgery, District Hospital, ]i&, Czech Republic

From September 1988 through March 1996, 300 patients (263 females, 37 males, mean age 39 years, range 17-62) underwent gastric banding for morbid obesity. Mean over-weight was 48.2 kg according to Broca’s formula. Upper pouch of the volume of 50 ccm, and calibrated stoma of 12 mm in diameter were created till December 1994; from then the pouch has been diminished to the volume of 15 ccm. In 297 patients a fixed band, using vascular polyester prothesis was applied by open procedure. In three patients Lap-Band (BioEnterics) was applied laparoscopically.

Mortality rate was 1.3% (all four patients died in the initial period of the study), morbidity rate ap- proached 12.5%. Postoperatively, patients were seen after 1, 3, 6, 12 and 24 months. The mean weight loss was 24%, 46%, 56% respectively, after 1 year amount- ing to 70%, after 2 years 57%.

We encountered stoma stenosis and dislocation of the band in three patients; two of them had to be reoperated. Band erosion occurred in one patient. As we noted in our follow-up, excess weight associated morbidity was reduced substantially.

Our findings confirm that gastric banding is an effective surgical procedure, achieving considerable and long-lasting weight reduction.

3 14 Obesity Surgery, 6, 1996

46. Efficacy of Adjustable Silicone Gastric Band System For Weight Loss Maintenance in Severely Obese Adults

Cornelius Doherty, James W. Maher

Department of Surgery, University of Iowa, School of Medicine, Iowa City, IA, USA

This is a preliminary report of the efficacy of an adjustable silicone gastric band (ASBG) placed at laparotomy to maintain weight loss over time. Forty adults had a history of being morbidly obese for 5 years or more and had been refractory to sustained weight loss with non-operative methods for weight reduction. Subjects had a mean height of 171 cm; mean weight of 147 kg; mean body mass index 50 (range 39-75). The upper gastric pouch was sized with a 25 ml balloon on a special calibration tube. The outlet diameter of the proximal pouch was measured to 12 mm using an electronic pressure sensor. The adjustment reservoir was implanted in the rectus ab- dominis sheath for percutaneous access.

There was no operative mortality. Results during the 3 years of observation are shown in Table 1.

Table 1. Results

Time Interval 1 year

Mean Body Weight 113kg

Body Mass Index 38

2 years

113kg

39

3 years

120 kg

40.5

In conclusion, 40 adults have had an ASGB system safely placed by laparotomy. This is an interval outcome report of the efficacy of the ASBG system observed at the University of Iowa Hospitals and Clinics to date. Long-term investigation is planned.

47. Laparotomic Stoma Adjustable Silicone Gastric Banding (SASGB): Preliminary Experience for the Therapy of Severe Obesity

P. Forestieri, L. Meucci, M. De Luca, C. Chiacchio

Department of Surgery, University ‘Federico II’ of Naples, Italy

Introduction: SASGB represents a very useful surgical procedure for the therapy of obesity as it can be completely reverted and allows us to regulate the gastric stoma diameter.

Materials and methods: Twenty-eight patients (26 females and two males) underwent surgery in the period between October 1994 and April 1996. Patients’ characteristics were: mean age 34 years (17- 51), mean body weight 127.1kg (95-180), mean

Absfracfs

height 160.1 cm (144-173), mean BMI 49.7 (36.4- 74.9), mean %IBW 215.1 (168.7-346.2). BMI ranged between 35 and 45 in 35.7% of patients, 45 and 55 in 46.4%, 55 and 65 in 14.3% and it was over 65 in 3.6% of cases. The percentage of IBW ranged between 131 and 160 in 3.6% patients, 161 and 225 in 60.7% of patients, and it was over 225 in 35.7% of patients. In all patients antibiotic and thromboembolic prophylaxis have been performed. Mean recovery time was 5.4 days and no solid food was administered in the first month.

Results: We found a mean weight loss of 19 kg (12-53) after 3 months, of 27.8 kg (19-65.5) after 6 months and 42.16 kg (31.3-86.5) after 1 year. After 3 months BMI was lower than 35 in 10% of patients (+ 10%). It ranged from 35 to 45 in 45% of patients ( + 9.3%) and was between 45 and 55 in the remaining 45% of cases (- 1.42%). No patients had a BMI higher than 55 ( - 17.2%). After 6 months a BMI lower than 35 was reported in 18.75% of patients (+ 18.75). BMI ranging from 35 to 45 was observed in 37.5% of patients ( + 1.8%), while it ranged between 45 and 55 in 43.75% of cases (- 2.67%). One year after banding 33.3% of patients had a BMI lower than 35 ( + 33.3%); 66.6% of patients had a BMI between 35 and 45 (+ 30.9%). A BMI over 45 was never observed ( - 64.3%). After 3 months the percentage of IBW ranged from 131 to 160 in 25% of patients (+ 21.43%), from 161 and 225 in 60% of patients ( - 0.7%), and was over 225 in 15% of cases (- 20.71%). After 6 months %IBW ranged from 131 and 160 in 37.5% of patients ( + 33.93%) from 161 to 225 in 62.5% of patients (+ 1.8%); a %IBW over 225 was never observed (- 35.71%). After 1 year %IBW was lower than 131 in 22.2% of patients (+ 22.2%), while it ranged from 131 to 160 in 11.1% of cases (+ 7.53%), and from 161 to 225 in 66.6% of patients ( + 5.9). The mean inflation volume of banding cham- ber was 2.89~~ (2.2-4); in two cases it was necessary to increase this volume (2.2+3.1 and 2.643.6) while it was reduced in two other cases (3+2.4 and 2.4-+1.8+0). We removed the banding in just one patient after 9 months as stoma stenosis and pouch dilatation occurred.

Conclusions: The data presented here show that among gastric restrictive procedures SASGB may be considered the elective surgical approach for severe obesity. Indeed, SASGB is extremely safe as well as effective and rarely followed by specific complications. Furthermore, a satisfactory body weight loss is usually obtained without big efforts from the patients. The only dietetic restriction is limited to intake of raw and solid meat.


Abstracts

48. Laparotomic and Laparoscopic Application of Adjustable Gastric Banding: a 5Year Study

Mario Lise, MD’, F. Favretti, MD’, G. Segato, MD’, F. De Marchi, MD’, G. Enzi, MD2, L. Busetto, MD2

Department of ’ Surgery 2 and ‘Infernal Medicine, Univer- sity of Padova, Italy

Since April 1990,270 obese patients underwent laparotomic application of ASGB; the weight loss is as follows in Table 1.

Table 1. Weight loss over 5 years

Years

0 1 2 3 4 5

BMI 47 37 35 34 35 35

%EWL 40 48 49 49 46

%IBW 212 169 158 155 155 159

kg 133 105 99 98 96 99

No. patients 270 231 109 109 70 30

Since September 1993, 104 patients underwent laparoscopic application of ASGB (Lap-Band); the results are shown in Table 2.

Table 2. Weight loss over 24 months

Months

0 6 12 18 24

BMI 44 37 34 31 29

%EWL - 34 48 54 62

%IBW 198 166 155 138 130

kg 118 97 93 a4 75

No. patients 104 45 23 14 7

Mortality rate was 0. The reoperation rate was 14.4% and 3.6% respectively in the two groups. Lap- Band is our first choice operation in selected patients.

49. Variations in the Operative Technique with the Swedish Adjustable Silicon Gastric Band Used For Morbid Obesity

T. Gudbjartsson’, D. Arvidsson’, H. Glise2, S. Gustavsson3, B. Hallerbtick“, J. Wenner’, P. Forsell

1 Helsingborg County Hospital, ’ NjiL Hospital, 3 Uppsala University Hospital and 4 Huddinge University Hospital, Sweden

Introduction: The Swedish adjustable silicone gastric banding (SAGB) was developed by Hallberg and

Forsell at Huddinge University Hospital in 1985. The procedure has been shown to be effective in achieving sustainable weight loss but, most importantly, complications are rare. An April 1996 over 600 operations have been done in Sweden, including over 100 laparoscopic procedures. The aim of this study was to define the operative techniques that have been used with the SAGB.

Method and results: This study included four hospitals where more than ten SAGB operations had been performed. Two different band placements have been used; (1) a ‘high placement with the posterior tunnelling of the band, just below the crus muscles; and (2) a ‘low’ placement with the posterior tunnelling cross- ing from the angle of His, to the lesser curvature, approximately 1.5-2.5 cm below the cardia. In addi- tion, both the ‘high and ‘low’ position can be combined with a row of anterior sutures between the stomach wall above and below the band, creating an invagination of the band. With the anterior sutures, it is also possible to adjust the pouch size by regulating the amount of the anterior stomach wall which is allowed to stay above the band. Thus actually four different techniques have been used with the SAGB.

Conclusion: The ‘low’ position with anterior sutur- ing is at the moment the most validated technique (I), although the other techniques as well seem to give comparatively good results regarding weight loss and morbidity. Further analysis of the results obtained with the various methods is necessary. A Swedish study group has been formed for this purpose.

50. Laparoscopic Gastroplasty (LASGB)

E. Chelala’, G.B. Cadiere, F. Favrett?, G. Segato’, M. Lise’, 0. Bath’, J. Bruyns’, M. Vertruyen’, J. Himpens’

1 Department of G.I. surgery, CHU Saint-Pierre, Brussels, Belgium, and ’ University of Padova, Italy

Patients: Between September 1992 and March 1995, 185 patients (35 males and 150 females), median age 38 (20-60), average weight 118 kg (74-175), percentage of excess weight as compared with the ideal weight 199 (105-268), Body Mass Index 43 (34-67), underwent laparoscopic gastroplasty according to Kuzmak’s banding technique. Thirty-seven patients had previous abdominal surgery. As comorbidity related factors: 18 oesophagitis (12 stage I, five stage II and one stage III), 27 hypertension treated medically; 18 diabetes type II, 16 hiatal hernia less than 2 cm and eight sleep apnea syndrome.

316 Obesity Surgery, 6, 19%

Absfracfs

Objectives: Gastric partition operations have been shown as the most effective in the treatment of morbid obesity. Adjustable silicone gastric banding is the more recent technique of gastric partition and consists of application around the stomach of a silicone inflatable band, 3 cm below the oesophago-gastric junction, performing a proximal pouch of about 20 ml in capacity, with adequate stoma. This operation is reversible, and the passage of foods can be controlled, depending on the patient’s need. The results of this treatment are improved by laparoscopic approach, avoiding respiratory complications, ileus, postoperative pain, wound infection and incisional hernia.

Materials and methods: From October 1994 until May 1996, 185 patients with morbid obesity without

‘selection underwent laparoscopic adjustable silicone gastric banding operation (LASGB). There were 26 males and 159 females, with a mean age of 36.33 years (range 18-62 years), mean body weight (BW) 119.2 kg (range 86-195 kg), Body Mass Index (BMI) 43.57kgmP2 (range 30.9-67.7kgm-‘), per cent of ideal weight (%IW) 190.3% (161-303). Nine patients needed conversion in open procedure; one because of gastric perforation; four because of impossibility to practise in the retrogastric tunnel; three because of immediate stenosis of gastric outlet; one because of vascular injury.

Results: All patients were checked monthly and the results of 114 patients after 3 months were: BW 102.45 kg, BMI 37.9kgm-‘, %IW 172.7% and per cent of excess weight loss (%EWL) 23.02%. In 19 patients after 12 months BW was 69.18 kg, BMI 29.4 kg m-‘, %IW 127% and %EWL 64%.

Conclusions: Therefore, regarding the technical procedure, the most important aspects are the creation of a retrogastric tunnel to make a passage for the band and the calibration of the stoma with an electronic sensor. The laparoscopic approach for surgical treatment of morbid obesity is a non invasive, safe and effective way to obtain an adequate weight loss, with social and physical benefits for the patients.

Method: A calibrated intragastric balloon is inflated with 15 cc of saline and then pulled back at the oesophagogastric junction. Dissection of the lesser curvature is initiated, starting at the equator level of the inflated balloon. Dissection is then taken 1 cm left to the phrenogastric ligament at the upper pole of the spleen. The band is looped around the stomach thus creating a 15 cc proximal pouch. Slipping of the band is prevented by several sero serous stitches on the anterior and posterior wall of the stomach. At the end of the procedure, an implantable reservoir (port-a-cath) is fixed on the anterior rectus sheath, just distal to the costal edge.

Results: Left liver hypertrophy impeded operation by laparoscopy in three patients. In eight patients, laparoscopy was converted. The early complications were: two perforations of the stomach on the first postoperative day necessitating reintervention for su- turing the perforation. One aspiration pneumonia was treated medically. One case of splenic injury occurred during the dissection. One case of slipping of the band occurred with consequence of reposition and fixation. Early operating morbidity decreased with our growing experience. Long-term complications were first seven cases of total and irreversible food intolerance accompanied by pouch dilatation, treated by removal of the band in two patients and repositioning in five with posterior fixation. One case of oesophageal perforation 2 months postoperatively caused by forced deglutition in a bulimic patient with a Pradder- Willi syndrome. The latter patient died. Mean operative time was 90min (40-180). Loss of excess weight was 20% in month 1, 35% in month 3, 50% in month 6, 60% in month 9 and 70% in month 12.

Conclusion: Adjustable silicone gastric banding is feasible laparoscopically. The technique is minimally invasive and does preserve the integrity of the stomach. It is reversible and adjustable since the diamter of the ring can be adjusted non-invasively, depending on the obtained weight loss. The efficacy of the procedure as far as weight loss is concerned is compara- ble with the other, more invasive techniques. Prelimi- nary results suggest a decrease in morbidity.

51. Laparoscopic Adjustable Silicone Gastric (LASGB) Banding For Treatment of Morbid Obesity

G. Natalini, G. Carloni, S. Cappelletti, L. Calzoni, F. Borgognoni, P. Roselli, F. Brecco-Lotto

Department of Surgery, Marsciano and Todi Hospital, Perugia, Italy

52. Laparoscopic Gastric Banding in Morbidly Obese Patients - Long-Term Results and Technical Aspects of the Procedure

Martin Fried, MD, PhD, Marie Peskova, MD, DSc, Mojmir Kasalicky, MD

First Surgical Department, Charles University Hospital, U nemocnice 2, 128 08, Prague 2, Czech Republic

A IO-year follow-up of gastric banding in morbidly obese patients is presented in this report. Since June


Absfracfs

1993 the gastric banding is performed as a laparoscopic procedure at First Surgical Department, Prague, Czech Republic. In the period 1986-1993 gastric banding was performed as an ‘open’ procedure. Com- paring the two methods, the weight loss results show no statistical difference, but there is a dramatic decrease in postoperative complication rate.

In the second part of this report technical aspects of laparoscopic gastric banding are discussed, mainly the question of upper gastric pouch volume assessment and the problem of the stoma diameter calibration. Some further problems concerning the band migration, slippage and pouch enlargement are reviewed in a long-term follow-up experience.

53. Laparoscopic Adjustable Silicone Gastric Banding: Surgical Technique of Placement and Results

P. Belva, M. Takieddine, P. Vaneukem

Hopifaux Civils du CPAS de Charleroi, Bd. l? ]anson, 92, B~OOO Charleroi, Belgium

The authors report their experience on 70 cases of morbidly obese patients operated on in the Depart- ment of Digestive Surgery in Charleroi (Belgium) by laparoscopy since July 1994.

The LASGB procedure (Laparoscopic Adjustable Silicone Gastric Banding) can first been described with a video which demonstrates the operative procedure and some details to avoid complications.

We have operated 70 patients (19% males/79% females) with a mean BMI of 43 kg me2 in respect with the indications of bariatric surgery.

The procedure was realized by laparoscopy for 91% of the patients and started open in 4% of the cases because of previous major surgery in the upper abdomen. The laparoscopic procedure has been converted in three patients (fatty omentum in male, suspicion of gaz embolism and posterior gastric wall perforation seen during the intervention).

We have observed some complications:

- Early: food intolerance in the postoperative time (20%) which can be avoided by deflation of the band after the operation.

- Late: total food intolerance with pouch enlargement and/or posterior gastric wall slippage through the band. These complications can be avoided by calibration of small pouches ( < 15 cc) and placement of the band just near the left crus with posterior stitch suture to avoid migration.

This complication was observed in 17 patients (18%) and need reoperation for replacement of the band or removal.

Our results are good in terms of weight loss but the follow-up time is too short to conclude definitively (< 2 years). The indications must be the same for any procedure for treatment of morbid obesity. We think that this procedure is NOT a plastic minimal invasive laparoscopic intervention.

54. Laparoscopic Adjustable Silicone Gastric Banding (LASGB): Initial Experience at the University of Naples, Italy

L. Angrisani’, A. Puzziello’, G. Romano’, A. Belfiore2, M. Lorenzo’, G. Esposito’, M. Fumo’, T. Santoro’, 0. Nicodemi’, G. Roina’, C. Falconi2, B. Tesauro’

‘I’ Clinica Chirurgica (Dir. Prof. B. Tesauro), ’ Servizio di Diefefica (Dir. Prof. C. Falconi), Universitir degli Studi di Napoli ‘Federico II’, Italy

LASGB procedure was clinically introduced in Belgium in 1993. Based on a 6-year experience of laparoscopic surgery (also in obese and super obese patients), LASGB has been started in Naples and Southern Italy in our unit in January 1996. Preoperative selection was performed by a multidisciplinary team approach following a detailed protocol. Under general anesthesia with patients in lithotomy position the band (INAMED srl) is laparoscopically positioned around the stomach 3 cm below the cardias. The proximal gastric pouch is measured (20 ml) and gastro- stenometric control of the new pylorus diameter is intraoperatively performed. This diameter can be postoperatively calibrated by puncturing the subcutaneous port which is connected with the band. Over 21 patients with BMI > 35 initially referred, five female (mean age 38.6 ? 9.9, range 27-50 y.o.; mean BMI 42 ? 3.1, range 39-46) received the LASGB. In one case laparoscopic cholecystectomy was associated. Mean operative time has been 260 ? 110 min, range 116-360. There were no intra- or postoperative complications with mean postoperative hospital stay of 3 2 1 days and complete recovery. Results in terms of weight loss, already achieved with open banding, await confirmation at follow-up. LASGB is a safe operation with optimal patient compliance which has opened the way to minimally invasive bariatric surgery.


55. Laparoscopic Adjustable Gastric Banding: Is Preoperative Esophageal Evaluation Necessary?

J. Melissas, J.G. Rabner, S. Kaiser, B. Jaffin, R.J. Greenstein

Mount Sinai School of Medicine, CUNY, New York, NY and VAMC, Bronx, NY, USA

Introduction: Gastric restrictive bariatric surgery is one of several operations available for weight loss. We have compared perioperative morbidity with esophageal pathology in patient populations considering gastric restrictive bariatric surgery.

Methods: An adjustable gastric band has been implanted at open surgery (ASGB, n = 18) since January 1994 and laparoscopically (LapBand, n = 21) since June 1995 at the Mount Sinai Medical Center, NY and VAMC, Bronx, NY, USA as part of a multicenter FDA moderated study (IDE no. GS-9034 Mount Sinai, IRB no. SU 93-535). Preoperatively an upper GI barium study is mandatory. Evolving concern about esophageal (dis)function has led us to evaluate additional tests. These included 24 h pH monitoring and more recently esophageal manometry.

Results: Mortality 0%. 24 h pH monitoring S/39 (20%) gave no useful information.

Table 1. Comparison of patients undergoing ASGB and

LapBand

ASGB h = 18) La&and h = 211 Excluded

UGI 18 21 3

Abnormal 5 (27%) 8 (38%) 2 (66%) Manometry 4 14 3 Abnormal 1 (25%) 7 (50%) 1 (33%)

Reoperations: ASGB 2/18 (11%) one band too loose and one twisted following ERCP LapBand; conversion 1121 (5%) reop 2/21 (9.5%). All three with Hiatal Hernia.

Conclusions: pH monitoring was poorly tolerated, gave no useful information and is no longer performed. Laparoscopic technical difficulties have been associated with hiatus hernias. Patients manifesting large hiatus hernia may be offered alternative procedures, in our case an open VBG. Preoperative esophageal manometry in our morbidly obese population is often and unexpectedly abnormal. These dysmotili- ties may prove to be a predictor of the long-term efficacy of gastric restrictive operations.

Abstracts

56. Swedish Adjustble Gastric Banding: Our Preliminary Experience Using the Laparoscopic Procedure

A. Catona, L. La Manna, E. Armeni, C. Sampiero, M. Gossemberg, A. La Manna”

Presidio Ospedaliero ‘C. Mim’, Az. USSL 42 Pavia, and “Fondazione 5 Maugeri’, Pavia, Italy

We have been routinely performing bariatric surgery for almost 15 years; since February 1992 we started treating our obese patients with laparoscopic gastric banding using a silastic band. Our good experience with the LGB combined with the everyday laparoscopic activity in our institution persuaded us to try laparoscopic placement of the Swedish Adjustable Gastric Banding for morbid obesity.

Materials and methods: The Swedish Adjustable Gastric Banding is a double layer silicone band with a dacron net in between. It has a balloon covering its inner surface. The balloon is connected to a subcutaneous port in a closed system by a thin tube. The system can be filled or evacuated and the gastric stoma diameter can therefore be adjusted. The surgical procedure is the same as that of laparoscopic gastric banding except for: the use of an 18 mm trocar that is required to introduce the band inside the abdominal cavity, the need to place subsutaneously a port, connected via a wide-loop tube to the band, supported by the lower part of the sternum. We usually don’t place any abdominal drain or a naso-gastric tube. At surgery the band is left empty and filling is usually not started until 4 weeks after surgery; the patient is immediately mobilized and begins a liquid diet the evening after operation. We usually discharge the patients from hospital on the first postoperative day.

Conclusion: We belive that SAGB is a good method for obesity surgery. It’s easy to perform and associated with a low operative risk and with few long-term complications. The results are highly predictable; provided that the band is put in the right place, weight loss can be adjusted to patient comfort. Most patients can expect to lose at least 75% of their overweight as shown by the 9-year follow-up by the Swedish authors.

57. Laparoscopic Adjustable Silicone Gastric Banding (LASGB): Facilitated Technique Using Flexible Instruments and a 70” Laparoscope

Jiirgen Wenner, Tomas Gudbjartsson, Dag Arvidsson

Helsingborg County Hospital, Sweden


Abstracts

Adjustable gastric banding in the treatment of morbid obesity has been used in more than 500 patients in Sweden since 1985. The method has shown to be safe and effective in achieving sustainable weight loss. The rapid development in laparoscopic surgery has made modified techniques accessible for this group of patients. In Helsingborg we use specially designed flexible instruments and a 70” laparoscope for the LASGB procedure.

The operation is performed under I.3 mmHg pneu- moperitoneum. Five extra long trocars 10111 mm are used. The dissection is started at the level between the left crus and the short gastric vessels creating a narrow opening in the avascular suspensory ligament. A similar narrow opening is then made 2-3 cm below the gastroesophageal junction on the lesser curve. The retrogastric channel is created using specially designed extra long and flexible instruments for blunt dissection and grasping. A 70” laparoscope provides excellent view of the operative field. The adjustable silicone band is introduced through an 18 mm trocar using the left lateral port and closed with intracorporeal tying. The greater curvature of the fundus is sutured over the band with two non-absorbable sutures. Finally the connecting tube to the silicon balloon is tunnelled to a subcutaneous injection port over the sternum.

A video explaining the essential steps of the operation is shown.

58. Complications of Laparoscopic Adjustable Silicone Gastric Banding (LASGB): Laparoscopic Management

Mitiku Belachew, MD

Service de Ckirurgie Universifaire Centre, Hospitalier Hutois, 2 Rue Trois Pants, 4500 HUY, Belgium

More than 260 patients have undergone laparoscopic banding in our institution since September 1993. There was no early complication. Some of these patients presented late complications related to the banding procedure. Pouch dilatation and/or stomach slippage has been the most serious complication of LASGB. Most of these patients have undergone laparoscopic correction of the problem. Procedures such as band removal, band replacement and reduction of stomach slippage have been performed laparoscopi- tally. No perioperative nor postoperative complications are encountered after the laparoscopic re-do procedures and the overall postoperative outcome was uneventful. This proved that laparoscopic re-do operations after LASGB are also minimally invasive

procedures. A short video will illustrate these procedures. Clinical data of the patients will also be analysed. Although the removal of a gastric band is considered a failure of the operation, it also proved that LASGB is a completely reversible procedure.

59. Problems in Laparoscopic Gastric Banding

M. Susewind, S. Klein, U. Kunath

Krankenkaus Am Urban, Abfeilung fib Allgemein- ckirurgie, Dieffenbackstr. 1, D-10967, Berlin

Since February 1993 morbid obesity has been treated at the Krankenhaus Am Urban, Berlin by gastric banding. Until July 1994 this operation was performed by laparotomy. The laparoscopic procedure has been done since August 1994. Our hospital was the first in Germany to do this operation. So far (February 1993- March 1996), 89 patients were operated, 77 of them the laparoscopic way.

We were confronted with the following intra- and postoperative problems:

1. Dislocation of the band n=l

2. Perforation of the stomach n=2

3. Distention of the pouch n=3

4. Distortion of the port n=4

5. Infection of the port n=5

6. Leakage of the port membrane n=6 7. Operation technically impossible n=7

The intra- and postoperative problems are either due to the surgical technique or the patients’ compliance. The above listed problems could be avoided by:

1. the correct adjustment of the size of the pouch, 2. the improvement of the operation technique, 3. the postoperative management (adjustment of

the band 4 weeks after implantation), 4. the correct selection and guidance of patients.

The follow-up study shows that most of these problems occurred within the first year of performing the laparoscopic gastric banding operation.

60. Reoperation for Total and Irreversible Food Intolerance After Laparoscopic Adjustable Silicone Gastroplasty Banding (LASGB)

E. Chelala, M. Vertruyen, G.B. CadiBre, J. Himpens, J. Bruyns

Department of GI surgery, St-Pierre Hospital, Brussels, Belgium


Abstracts

In spite of good gastric banding effect in many patients, we refer to three women with late complications:

(I) Thirty-years-old, banding with BMI 58 kg m-‘, 3 years without medical control, a loss of 55 kg, came with vomiting, dehydration, hypokalemia, hyperazo- temia, BMI 34 kg m- 2, X-ray and gastroscopy complete block, during surgery (First clinic of surgery) dilatation of stomach treated with gastrogastroanasto- mosis parallel to gastric banding, which was found to be free.

(2) Fifty-two-years-old, banding with BMI 56 kg mP2, loss of 50 kg during 3 years, last 2 years eating large amounts of food without problems, weight gain 10 kg, X-ray 3 cm diameter of banding, normal peristaltics, indicated to reoperation.

(3) Fifty-two-years-old, BMI 45 kg m-‘, banding combined with cholecystectomy, loss of 30 kg in 6 months, daily vomiting without surgical reason, no ion disorder, unable to follow the diet.

Conclusion: Most problems after gastric banding occur in patients who do not have medical control and who are not able to follow the diet. There is no surgical reason for these complications.

Between September 1992 and November 1995, 88 LASGB were performed. Four reoperations had to be performed for total and irreversible food intolerance. The patients were three females and one male, aged 30, 35, 39 and 44 years, with an initial weight of 96, 115, 124 and 162 kg and a Body Mass Index (BMI) of 42, 45, 57, 68. Indication for the new procedure was total and irreversible food intolerance. Noteworthy, neither one of the four patients had had posterior fixation of the lap band. All reoperations were performed laparoscopically. No new sites for the cannulas were chosen. The lap band itself cannot be seen at first glance. The procedure starts with the dissection of the adhesions between the liver and the anterior wall of the stomach. The ring has to be freed entirely. To do so, the tight fibrous capsula around it is incised horizontally on the anterior side, until the gastro- splenic ligament is reached. Subsequently, a window is made in the flaccid part of the lesser omentum in order to enter the lesser sac. The posterior side of the fibrous capsula is then incised also. Hence, the entire band is free. The part of the stomach that has slipped cephalad can now be reduced through the band. If this manoeuvre is unsuccessful, a mini lap can be performed in order to unlock the band. The band is then repositioned after calibrating the gastric pouch to 15 cc. Four sero serous stitches anteriorly and one posteriorly anchor the band safely in place. There were no postoperative problems after the re-do in the four patients mentioned. A liquid diet was prescribed for 3 months postoperatively. The band itself is not visible at first exploration because of the hyperemic fibrous capsula around it. Incision is best performed by hook cautery or by coagulating scissors. Reduction of the slipped stomach through the band can be hazard- ous at times. This is due to the volume of herniated stomach on one hand and to the presence of edema of the wall on the other hand. On one occasion, the authors had to use a Kelly clamp introduced by mini lap to open the band and to reduce the dilated stomach pocket. To avoid slippage and dilatation of the proximal pouch, it appears imperative to fix the posterior wall of the stomach around the band. Finally, it might be worthwhile to develop a tool permitting the unlocking of the band by laparoscopic means.

61. Some Late Complications After Gastric Banding

$&pan SvaCina, JiK Sanka

Third Clinic of Medicine, First Medical Faculty, Charles University, Prague, Czech Republic

62. Adjustable Silicone Gastric Banding - Detection of Leakage with Thallium-201

K. Miller*, I. Rettenbacher’, F. Hell3

1 Second Surgical Department, 2 Department of Nuclear Medicine and Endocrinology, Landeskrankenanstalten, Salzburg, 3 A.5 Krankenkaus, Hallein

The detection of a leakage in the system of the adjustable silicone gastric band may be difficult. Gas- trografin injection into the port should be avoided because it acts like a glue and blocks the system. The knowledge of the location of the leakage is essential either to change the port or to change the whole system. This means planning an operation in local anesthesia to change the port or performing a laparotomy.

We have elaborated a technique for detection of leakage without X-ray. A small amount of local ane- sthetic is injected under the skin. A 22-gauge spinal needle with a &way stopcock 360” is directed to the center of the port. A syringe containing saline and a syringe containing Thallium-201 is connected to the 4-way stopcock which is connected to the needle. The needle is pushed into the port. The position is confirmed by injection and aspiration of saline. Two ml of TL-201 (74 MBq) is injected to locate the leakage


Abstracts

in the system with planar images with a gamma camera (Elscint SP 6), 30min, 2, 3 and 24 h after injection. The late pictures are essential because of slow migration. With this technique the location of the leak could be detected, and laparotomy could be avoided in case of leaking port.

63. Failed Bariatric Surgeries Are Easily Convertable to Adjustable Silicone Gastric Banding (ASGB)

Lubomyr I. Kuzmak, MD, ScD

Surgical Center for Obesity, 340 E. Northfield Rd, Living- ston, IV”, USA

Many different bariatric surgical procedures have been used to treat severely obese patients. Most of the patients lose weight and maintain the loss without complications. But a group of the patients will require a secondary intervention to deal with a specific problem (e.g. weight gain, vomiting, other complications or failure of their initial procedure). The secondary intervention more often than not is a re-do of the existing procedure or conversion to a procedure that can lead to severe problems. Starting in 1983, 65 patients (eight males and 57 females, average age 40.1 years) requesting a secondary intervention were offered a conversion to either a Silicone Gastric Band- ing (SGB) (n = 48) or Adjustable SGB (ASGB) (n = 17). Conversion was sought by 75% due to inadequate weight loss and by 25% due to complications resulting from prior bariatric procedures. The procedures converted included several versions of gastric bypass, gastroplasty or gastric wrapping. Conversion- related mortality was 0%. All but one of the 65 patients have maintained a lower weight than their preoperative weight. Average IO-year weights for 14 prior Horizontal Gastroplasties converted to SGB are 151% of Ideal. As with any bariatric procedure, there were patients who required further revision [band slippage or erosion (3.1%), stoma related (13.8%), weight gain (7.7%)]. To date, ten of the 65 conversion patients have had their band removed. Introduction of ASGB (1986) resulted in fewer stoma-related prob-

lems and better weight loss. ASGB should be considered for use as a conversion procedure for patients with existing prior bariatric procedures, regardless of what type, as it allows the surgeon non-surgical access to the stoma size.

64. Two Cases of Conversion Of Vertical Ring Gastroplasty Into Adjustable Silicone Gastric Banding

Jerome Dargent, PhD

Private Practice, Polyclinique de Rillieux, Lyon, France

Since May 1995, we have adopted laparoscopic adjustable silicone gastric banding (LASGB) as an alternative to vertical ring gastroplasty (VRG) to treat morbid obesity. Besides, it seemed ASGB was an interesting procedure when VRG had failed, and no iterative procedure could be attempted again, which occurred in two cases. Because of adhesions, the laparoscopic way was not used in both cases. The size of the pouch and the staple line were not obstacles to ASGB.

Case no. 1: A 53-year-old woman weighing 111 kg (BMI = 46) had VRG in July 1994. One year later, she was satisfied with a 54 kg weight loss, but had irreducible food intolerance, despite which one could not point out a malfunction of the pouch or of the ring. A removal of the ring was performed on October 1995, and a 1Ocm diameter silicone band placed. The band was not inflated until she had regained weight 5 months later.

Case no. 2: A 33-year-old woman weighing 100 kg (BMI = 40) had VRG in March 1994. The weight loss was 45 kg 18 months later, then she gained weight again. Endoscopy and barium swallow showed both staple line disruption and band erosion. A removal of the ring was performed on March 96, and a 9.75 cm diameter silicone band placed, and inflated at the same time with 2 cc saline.

ASGB seemed to us the alternative procedure of choice when dismantling of VRG was required in such cases, where a new stapling or the placement of a new ring could have had worse consequences than primary complications.


abstracts of the first congress of the international federation for the surgery of obesity

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