Bruno M. Balsiger

Ten and more years after vertical banded gastroplasty as primary operation for morbid obesity

Long-term follow-up (>l0 years) after vertical banded gastroplasty (VBG) is almost nonexistent. The aim of this study was to determine long-term outcome after VBG in a group of 71 patients studied prospectively. Seventy-one consecutive patients with morbid obesity (54 women and 17 men; mean age 40 years [range 22 to 71 years]) underwent VBG from 1985 to 1989 and were followed prospectively. Follow-up was obtained in 70 (99%) of the 71 patients. Weight (mean ± standard error of the mean) preoperatively was 138 ±3 kg and decreased to 108 ±2 kg 10 or more years postoperatively. Body mass index decreased from 49 ±1 to 39 ±1. Only 14 (20%) of 70 patients lost and maintained the loss of at least half of their excess body weight with the VBG anatomy. Vomiting one or more times per week continues to occur in 21% and heartburn in 16%. Fourteen patients have undergone conversion from VBG to Roux-en-Y gastric bypass (11 patients) or other procedures (3 patients) because of a combination of inadequate weight loss in 13 patients, gastroesophageal reflux in five, and frequent vomiting in four. Only 26% of patients after VBG have maintained a weight loss of at least 50% of their excess body weight; 17% underwent bariatric reoperation with good results. Thus VBG is not an effective, durable bariatric operation.

Bariatric surgery. Surgery for weight control in patients with morbid obesity.

Morbid obesity has become a health crisis in the United States. Medical programs developed at nonoperative attempts to lose (and maintain) an adequate weight loss are largely unsuccessful. Bariatric surgery has been proven to be effective at inducing and maintaining a satisfactory weight loss to decrease weight-related comorbidity. Bariatric operations include procedures that decrease mechanically the volume capacitance of the proximal stomach (vertical banded gastroplasty, laparoscopic gastric banding) or decrease the proximal gastric capacitance and establish a partial selective malabsorption (gastric bypass and its modifications, partial biliopancreatic bypass, and duodenal switch with partial biliopancreatic bypass). These operations should induce a loss of at least 50% (or more) of excess body weight. Not all patients are candidates for these procedures, and the best results are obtained by a multidisciplinary team (including nutritionist, physician, dietitian, psychologist or psychiatrist interested in eating disorders, and surgeon).

Malabsorptive procedures for severe obesity: comparison of pancreaticobiliary bypass and very very long limb Roux-en-Y gastric bypass

The aim of this study was to determine the efficacy and safety of two malabsorptive procedures for severe obesity. Prospectively collected data from eight men and three women who underwent partial biliopancreatic bypass (PBB) and 19 men and seven women who underwent very very long limb Roux-en-Y gastric bypass (WLGB) for superobesity (preoperative weight >225% above ideal body weight) were evaluated. Age (42 ±3 years and 40 ±2 years), body mass index (64 ±4 kg/m2 and 67 ±3 kg/m2), and percentage of excess body weight (183% ±17% and 203% ±12%) were similar (mean ± standard.error of the mean). Median follow-up was 96 months (range 72 to 108 months) and 24 months (range 18 to 60 months) for the PBB and WLGB groups, respectively. Weight loss expressed as percentage of excess body weight was 68% ±4% 2 years and 71% ±5% 4 years after PBB, and 53% ±7% 2 years and 57% ±5% 4 years after VVLGB. Current body mass indexes are 37 ±2 kg/m2 and 42 ±2 kg/m2 in the PBB and WLGB groups, respectively. Hospital mortality was zero. Morbidity occurred in five patients after WLGB (wound infection in four, wound seroma in one, and pulmonary embolus in one) and in two patients after PBB (abscess in two, anastomotic leak in one, and gastrointestinal bleeding in one). After PBB, one woman died of refractory liver failure 18 months postoperatively and two other patients developed metabolic bone disease. No such known complications have occurred to date after VVLGB. We conclude that VVLGB is safe and effective for clinically significant obesity, results in sustained weight loss, and improves quality of life.

Psychosocial Factors and 2-Year Outcome Following Bariatric Surgery for Weight Loss

Background: How psychosocial factors may impact on weight loss after bariatric surgery is not well understood. This lack of knowledge is problematic, because there is a high prevalence of psychosocial distress in patients seeking treatment for obesity in hospital-based programs. The purpose of this study was to examine the relationship between preoperative psychosocial factors and eventual weight loss. Method: Between 1987 and 1998, all individuals undergoing Roux-en-Y gastric bypass for weight loss in our institution had psychologic preoperative evaluations. Patients who were followed prospectively were studied. The relation of having received mental health treatment to percentage of excess weight loss at 2 years is examined using t-tests. Results: 62 women and 18 men completed a 2-year follow-up. Patients who had received treatment for either substance abuse (n=10) or psychiatric co-morbidity (n=39) lost more weight compared with those without such histories (P<0.05, P <0.001 respectively). Conclusion: Given these results, it is plausible that a history of having received either psychiatric treatment for a disorder or counseling for substance abuse should not be a contraindication to bariatric surgery, and, in fact, may be prognostic of favorable outcome. Further research examining psychosocial factors and outcome from bariatric surgery is clearly warranted.

Gastroesophageal reflux after intact vertical banded gastroplasty: Correction by conversion to Roux-en-Y gastric bypass

Symptomatic gastroesophageal reflux disease is common in our experience after vertical banded gastroplasty. Our aim was to determine the safety and efficacy of Roux-en-Y gastric bypass in the treatment of symptomatic gastroesophageal reflux disease complicating vertical banded gastroplasty. We evaluated prospectively collected data on 25 patients who underwent revisional bariatric surgery because of severe gastroesophageal reflux disease after vertical banded gastroplasty. Only 4 of 25 patients had gastroesophageal reflux disease symptoms prior to vertical banded gastroplasty. Endoscopic findings in 24 patients included esophagitis (SS%), Barrett’s esophagus (28%), pouchitis (29%), and gastritis (2 1%); 7 (28%) of 25 patients had evidence of stenosis at the pouch outlet. Mean follow-up (complete in all 2 5) after Roux-en-Y gastric bypass was 3 7 ±7 months (range 3 to 102 months). There were no deaths. Post-operative complications occurred in six patients: pneumonia in two, wound infection in two, prolonged drainage of the defunctionalized stomach via gastrostomy in one, and fever in one. Median hospitalization was 7 days (range 5 to 43 days). At follow-up (3 7 ±7 months), 24 (96%) of 25 are completely or almost completely symptom free. Body mass index was 33 ±2 kg/m2 before and 28 ±2 kg/m2 after Roux-en-Y gastric bypass (P = 0.001). Symptoms of gastroesophageal reflux disease are common after vertical banded gastroplasty. Conversion to Roux-en-Y gastric bypass is safe, relieves gastroesophageal reflux disease, and promotes further weight loss. Moreover, maladaptive eating (vomiting, and so forth) induced by vertical banded gastroplasty is relieved.

Problems of Reconstruction during Pancreatoduodenectomy

Pancreatoduodenectomy may be a difficult operation, not only during the resectional part of the procedure, but also during reconstruction. Usually, these problems are due to local conditions of the organs/tissues, such as small diameter of the common bile duct or pancreatic duct, friable soft pancreas, vascular anomalies, etc. Reconstruction may also be problematic because of the hemodynamic instability of the patient during surgery (subsequent to massive hemorrhage), and in those unusual cases, delayed reconstruction may be a life-saving, wise choice.

Adrenergic denervation hypersensitivity in ileal circular smooth muscle after small bowel transplantation in rats

Effects of small bowel transplantation (SBT) onileal motility are unknown. The aim of the present studywas to investigate changes in spontaneous contractileactivity and sensitivity to cholinergic and adrenergic agents in the ileal circular muscleafter SBT in rats. Orthotopic SBT was performed insyngeneic rats to avoid immune phenomena. Distal ilealcircular muscle strips from rats one week (N = 10) and eight weeks (N = 10) after SBT werestretched to optimal length (Lo), and basalspontaneous activity at Lo was measured. Dose-responseexperiments to the cholinergic agonist bethanechol (Be,10-8-10-4 M) were performed in the presence oftetrodotoxin (TTX, 10-6 M) and to theadrenergic agonist norepinephrine (NE,10-8-10-4 M) with or without TTX.ED50 (negative log of drug-concentration that induced 50% effect) was calculated. We also studiedrats with selective jejunoileal ischemia/reperfusion,intestinal transection/reanastomosis, naive controls,and sham operated controls (N ≥ 8/group). Spontaneous basal activity did not differ among groups.Sensitivity to Be was not different in rats after SBT orin other groups compared to control tissue. After SBT,hypersensitivity to NE was shown by a significant increase of ED at one and eight weeks after SBT(5.1 ± 0.3 vs 6.2 ± 0.4 and 6.2 ±0.2, respectively; P < 0.05) regardless of thepresence of TTX. No hypersensitivity was observed afterischemia-reperfusion, intestinal transection-reanastomosis, or shamoperation. It is concluded that ileal hypersensitivityto NE was related to the extrinsic denervation obligatedby the transplantation procedure, possibly mediated through an increase in number of receptors onsmooth muscle, not on the enteric nerves.

Small bowel transplantation induces adrenergic hypersensitivity in ileal longitudinal smooth muscle in rats

Our aim was to determine the effects of small bowel transplantation on contractility of longitudinal muscle in the rat ileum. Full-thickness longitudinal muscle strips from four groups of rats (naive controls, sham-operated controls, and 1 week and 8 weeks after syngeneic orthotopic small bowel transplantation) were studied in vitro. Neither baseline contractility nor response to neural blockade (tetrodotoxin) or adrenergic/cholinergic blockade differed among the groups. Although the dose response to the cholinergic agonist bethanechol and to nitric oxide did not differ among groups, the ED50 (negative log of concentration giving half-maximal effect) for the adrenergic agonist norepinephrine was increased 1 week and 8 weeks after transplantation, indicating a hypersensitivity response not blocked by tetrodotoxin. Nonadrenergic, noncholinergic inhibitory responses to electrical field stimulation were of greater amplitude and occurred at lesser frequencies (≤5 Hz) 1 week after small bowel transplantation, but returned to control values 8 weeks postoperatively. These inhibitory responses were blocked by the nitric oxide synthase inhibitor L-NMMA but not by methylene blue, a nonspecific inhibitor of guanylate cyclase. Small bowel transplantation induces a persistent adrenergic denervation hypersensitivity at the muscle and appears to upregulate, at least transiently, other inhibitory mechanisms mediated by neural release of nitric oxide. Small bowel transplantation does not alter muscle response to cholinergic pathways. These alterations in smooth muscle contractility may affect gut function early after clinical small bowel transplantation.

Axillary lymph node dissection in breast cancer : Current status and controversies, alternative strategies and future perspectives

Axillary lymph node dissection (ALND) has traditionally been considered as a standard procedure in the surgical management of patients with breast cancer. The goals of ALND in breast cancer surgery are: (a) to provide accurate prognostic information, (b) to maintain local control of the disease in the axilla and (c) to provide a rational basis for decisions about adjuvant therapy. Although controversial, ALND may also be associated with a small therapeutic benefit. Recently, the question of whether ALND is needed for every patient with invasive breast cancer has been the subject of ongoing debate in the literature. This is mainly due to the widespread use of adjuvant systemic therapy for patients with node-negative breast cancer and to the increasingly frequent detection of small invasive cancers by mammographic screening; the majority of these patients have negative axillae. Sentinel lymph node (SLN) biopsy is a new, promising, minimally invasive procedure, which accurately predicts nodal status with minimal morbidity, and reserves ALND for patients with positive SLN biopsies. However, this method is still investigational. Partial (levels I and II) ALND remains the gold standard in the surgical management of patients with breast cancer.Axillary lymph node dissection (ALND) has traditionally been considered as a standard procedure in the surgical management of patients with breast cancer. The goals of ALND in breast cancer surgery are: (a) to provide accurate prognostic information, (b) to maintain local control of the disease in the axilla and (c) to provide a rational basis for decisions about adjuvant therapy. Although controversial, ALND may also be associated with a small therapeutic benefit. Recently, the question of whether ALND is needed for every patient with invasive breast cancer has been the subject of ongoing debate in the literature. This is mainly due to the widespread use of adjuvant systemic therapy for patients with node-negative breast cancer and to the increasingly frequent detection of small invasive cancers by mammographic screening; the majority of these patients have negative axillae. Sentinel lymph node (SLN) biopsy is a new, promising, minimally invasive procedure, which accurately predicts nodal status with minimal morbidity, and reserves ALND for patients with positive SLN biopsies. However, this method is still investigational. Partial (levels I and II) ALND remains the gold standard in the surgical management of patients with breast cancer.

Functional changes in nonadrenergic, noncholinergic inhibitory neurons in ileal circular smooth muscle after small bowel transplantation in rats

This experiment was designed to determinemechanisms of change in nonadrenergic, noncholinergic(NANC) inhibitory neurons in the ileum after small boweltransplantation (SBT) in the rat and whether nitric oxide (NO) serves as an important NANCinhibitory neurotransmitter in the rat ileum. Eightgroups of rats (N ≥ 8 rats/group) were studied:neurally intact unoperated controls; rats one week afteranesthesia and sham celiotomy; and separate groups one andeight weeks after either 40 min of cold ischemia of thejejunoileum, combined jejunal and ileal intestinaltransection/reanastomosis, or orthotopic SBT of the entire jejunoileum. Contractile activitywas evaluated in full-thickness ileal circular musclestrips under isometric conditions. Spontaneous activitydid not differ among groups. In all groups, exogenous NO, NG-monomethyl-L-arginine(L-NMMA, an NO synthase inhibitor), and methylene blue(soluble guanylate cyclase inhibitor) had no effect onspontaneous activity, while 8-bromocyclic guanosinemonophosphate (8Br-cGMP) inhibited contractile activity inall groups. Low frequency (2-10 Hz) electrical fieldstimulation (EFS) inhibited contractile activity only incontrol and SBT groups; L-NMMA and methylene blue did not alter the response to EFS in any group.These results suggest that each aspect of the SBTprocedure, ischemia/reperfusion injury, disruption ofenteric neural continuity by intestinal transection, and extrinsic denervation, alter function ofenteric ileal inhibitory neurons separately early (oneweek) after operation. NO, a known inhibitoryneurotransmitter in other gut regions, does not affectileal circular muscle in neurally intact tissue normediate functional changes in inhibitory nerve functionnor smooth muscle contractility after SBT.