Bradley Schwack

Improvement in nonalcoholic fatty liver disease and metabolic syndrome in adolescents undergoing bariatric surgery.

BACKGROUND Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in children. It is linked to obesity and the metabolic syndrome (MS), predisposing to future cirrhosis. The objective of this study was to demonstrate the effects that weight loss achieved with laparoscopic adjustable gastric band (LAGB) has on the metabolic parameters and NAFLD scores of obese adolescents with evidence of fatty liver disease. METHODS Adolescents undergoing LAGB were evaluated for NAFLD with evidence of fatty liver on preoperative sonogram, serum biochemistry, or both between 2005 and 2011. Primary endpoint was change in NAFLD scores after LAGB and secondary endpoint change in MS criteria. RESULTS Fifty-six out of 155 adolescents had evidence of fatty liver disease at presentation. The group consisted of 17 (30%) male and 39 (70%) females, mean age 16.1 years (range 14-17.8 yr). Preoperative body mass index (BMI) was 48.8 kg/m(2) (±7) dropping to 37.9 kg/m(2) (±8.3) at 12 months and 36.8 kg/m(2) (±8.2) at 24 months. Fifteen (27%) patients met the criteria for MS. When comparing 1-year postsurgery to presurgery, the NAFLD score decreased by an average of .68 (SD = 1.03, P<.01). The 2-year NAFLD score decreased by a mean of .38 (SD = .99, P = .01). The reoperation rate for band/port related complications was 10.7% at 2 years with no mortality. MS rates improved from 27% to 2% at 2 years (P< .01). CONCLUSIONS LAGB is a safe and effective operation for obese adolescents with NAFLD. There was significant improvement in NAFLD scores and resolution of MS.

Safety and efficacy of laparoscopic adjustable gastric banding in patients aged seventy and older

BACKGROUND Life expectancy is increasing, with more elderly people categorized as obese. The objective of this study was to assess the effects of laparoscopic adjustable gastric banding (LAGB) on patients aged ≥ 70 years. METHODS This was a retrospective analysis of patients aged ≥ 70 years who underwent LAGB at our university hospital between 2003 and 2011. The data included age, weight, body mass index (BMI), and percentage excess weight loss (%EWL) obtained before and after gastric banding. Operative data, length of stay, postoperative complications, and resolution of co-morbid conditions were also analyzed. RESULTS Fifty-five patients aged ≥ 70 years (mean 73 years) underwent gastric banding between 2003 and 2012. Mean preoperative weight and BMI were 123 kilograms and 45 kg/m(2), respectively. On average, each patient had 4 co-morbidities preoperatively, with hypertension (n = 49; 86%), dyslipidemia (n = 40; 70%), and sleep apnea (n = 31; 54%) being the most common. Mean operating room (OR) time was 49 minutes, with all patients discharged within 24 hours. There was 1 death at 4 years from myocardial infarction, no intensive care unit admissions, and no 30-day readmissions. Mean %EWL at 1, 2, 3, 4, and 5 years was 36 (± 12.7), 40 (± 16.4), 42 (± 19.2), 41 (± 17.1), 50 (± 14.9), and 48 (± 22.6), respectively. Follow-up rates ranged from 55/55 (100%) at 6 months to 7/9 (78%) of eligible patients at 5 years and 2/2 (100%) at 8 years. Complications included 1 band slip at year 5, 1 band removed for intolerance, and 1 port site hernia. The resolution of hypertension, dyslipidemia, sleep apnea, lower back pain, and non-insulin-dependent diabetes was 27%, 28%, 35%, 31%, and 35%, respectively. CONCLUSIONS LAGB as a primary treatment for obesity in carefully selected patients aged ≥ 70 can be well tolerated and effective with moderate resolution of co-morbid conditions and few complications.

Sustained weight loss after gastric banding revision for pouch-related problems.

Objective:To assess the impact of revisional surgery after laparoscopic adjustable gastric banding (LAGB) on weight loss at 12 and 24 months. Background:There is no uniform consensus as to the optimal procedure for patients requiring revision after LAGB. Few studies address the issue of weight loss after band salvage procedures, despite this being a critical factor in deciding which reoperative procedure to choose. Methods:A retrospective analysis was conducted of adult patients who underwent LAGB from January 1, 2001 to June 30, 2009 at a single institution. Patients who required revision for pouch-related problems including band slippage, pouch dilation, and hiatal hernia were studied. Demographic data, body mass index (BMI), percentage excess weight loss (% EWL), and operative details were recorded. Weights were recorded at 12 and 24 months after revision. These were compared with initial weight, weight before revision, and weight in patients who did not have a reoperation. Results:Of 3876 patients, 390 patients were included in analysis of weight outcomes after revision. The procedure-related mortality was 0%. Early (30-day) complications occurred in 0.5%, late complications (erosion) in 0.5%, and 29 patients (7.4%) required a second revision. For patients undergoing revision, the initial weight was 124.06 ± 21.28 kg and BMI was 44.80 ± 6.12 kg/m2. At reoperation, weight was 89.18 ± 20.51 kg, BMI was 32.25 ± 6.50 kg/m2 and, %EWL was 54.13 ± 21.80%. Twelve months postrevision, weight was 92.24 ± 20.22 kg, BMI was 33.32 ± 6.41 kg/m2, and %EWL was 48.81 ± 22.71%. Weight was 92.42 ± 19.91 kg, BMI was 33.53 ± 6.25 kg/m2, and %EWL was 47.50 ± 22.91% twenty-four months postrevision. Conclusions:Reoperation for pouch-related problems after LAGB is safe and effective. Weight loss is maintained after reoperation.

Surgical management and outcomes of patients with marginal ulcer after Roux-en-Y gastric bypass

BACKGROUND Marginal ulcers (MUs) are potentially complex complications after Roux-en-Y gastric bypass. Although most resolve with medical management, some require surgical intervention. Many surgical options exist, but there is no standardized approach, and few reports of outcomes have been documented in the literature. The objective of this study was to determine the outcomes of surgical management of marginal ulcers. METHODS Data from all patients who underwent surgical intervention between 2004 and 2012 for treatment of MU after previous Roux-en-Y gastric bypass were reviewed. RESULTS Twelve patients with MUs underwent reoperation. Nine patients had associated gastrogastric fistulae (75%). The median time to reoperation was 43 months. Ten patients underwent subtotal gastrectomy, of which 9 had a revision of the gastrojejunal anastomosis and 1 did not. One underwent total gastrectomy with esophagojejunal anastomosis for ulcer after previous revisional partial gastrectomy, and 1 patient underwent video-assisted thoracoscopic truncal vagotomy for persistent ulcer-related bleeding in the early postoperative period. Three patients (25%) experienced postoperative complications associated with revisional surgery requiring reoperation. At median follow-up time of 35 months, 7 patients (58%) had chronic abdominal pain, and 4 patients (33%) had intermittent diarrhea. Three patients (25%) were lost to recent follow-up. None had recurrence of MU. CONCLUSION Patients can undergo one of several available surgical interventions, including laparoscopic subtotal gastrectomy with gastrojejunostomy revision. Though this appears to offer definitive treatment of MU, its benefits must be weighed against the increased risk of significant postoperative complications and chronic symptoms related to revisional surgery.

Gastric Band Conversion to Roux-en-Y Gastric Bypass Shows Greater Weight Loss than Conversion to Sleeve Gastrectomy: 5-year Outcomes

BACKGROUND Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) are often used as revisional surgeries for a failed laparoscopic adjustable gastric band (LAGB). There is debate over which procedure provides better long-term weight loss. OBJECTIVE To compare the weight loss results of these 2 surgeries. SETTING University hospital, United States. METHODS A retrospective review was conducted of all LAGB to RYGB and LAGB to LSG surgeries performed at a single institution. Primary outcomes were change in body mass index (BMI), percent excess BMI lost, and percent weight loss. Secondary outcomes included 30-day complications and reoperations. RESULTS The cohort included 192 conversions from LAGB to RYGB and 283 LAGB to LSG. The baseline age and BMI were similar in the 2 groups. Statistical comparisons made between the 2 groups at 24 months postconversion were significant for BMI (RYGB = 32.93, LSG = 38.34, P = .0004), percent excess BMI lost (RYGB = 57.8%, LSG = 29.3%, P < .0001), and percent weight loss (RYGB = 23.4%, LSG = 12.6%, P < .0001). However, the conversion to RYGB group had a higher rate of reoperation (7.3% versus 1.4%, P = .0022), longer operating room time (RYGB = 120.1 min versus LSG = 115.5 min, P < .0001), and longer length of stay (RYGB = 3.33 d versus LSG = 2.11 d, P < .0001) than the LAGB to LSG group. Although not significant, the conversion to RYGB group had a higher rate of readmission (7.3% versus 3.5%, P = .087). CONCLUSION Weight loss is significantly greater for patients undergoing LAGB conversion to RYGB than LAGB to LSG. However, those undergoing LAGB conversion to RYGB had higher rates of reoperation and readmission. Patients looking for the most effective weight loss surgery after failed LAGB should be advised to have RYGB performed, while also understanding the increased risks of the procedure.

Complications of Gastric Bands

Laparoscopic adjustable gastric banding (LAGB) is a restrictive bariatric operation. The procedure involves the placement of a gastric band around the upper part of the stomach, just below the gastroesophageal junction. This device is adjustable, and the procedure is devoid of any resection—no staples used at all. The procedure is unique in the fact that it requires strict follow-up with subsequent “fills” of the band in order to attain the proper level of satiety. These fills are performed in the office with a non-coring Huber needle. A patient’s success with a LAGB is directly proportional to the patient’s ability to follow up and the surgeon’s availability to provide such follow-up.

Mo1678 30-Day Readmission After Laparoscopic Sleeve Gastrectomy - A Predictable Event?

Corrosive injuries to the upper gastrointestinal tract is one of the difficult problems to treat. It resultsin major morbidity and mortality. Corrosives are substances which corrode and destroy tissues through direct chemical reaction. The strictures can present with various severity in pharynx, oesophagus and stomach. Isolated gastric strictures are less observed. Although corrosive substances can reach rapidly from oesophagus onto the stomach, they get stagnant in the prepyloric region because of pyloric spasm. The stricture may involve antrum, body and the pyloroduodenal area or diffusely the entire stomach depending upon the rapidity of spread of the ingested corrosive substance. We have classified the gastric strictures so as to optimize the treatment options based on the subtype. We herewith formulate a newworking classification. Treatment options according to the classified subtypes are also suggested to optimize the outcome. Data: 48 patients of isolated gastric stricture were included in this study. We had 20 patients with Type I; 12 underwent arcade preserving antrectomy, 14 had Bilroth Type I and 6 had Bilroth Type II restoration. We had one Type IIA; managed by strictureplasty. Four Type IIB; managed with pylorus preserving antrectomy. We had three Type III; treated by circumferential sleeve resection and gastrogastrostomy. We had five Type IV; managed with total gastrectomy. We had one Type V; managed by limited oesophagogastrectomy. We had three Type VI; managed by gastrojejunostomy as these patients had first part duodenal involvement. We had eleven Type VII; called as gastrocele; managed with antrectomy and colon pullup in five, gastrojejunostomy and colon pullup in three and antrectomy and retrograde dilatation in two. One patient died due to massive aspiration prior to treatment. There were acceptable morbidiy and two mortality in this series. Our new working formulation will form the basis of care in patients with gastric corrosive strictures.