Daniel Cottam

A case-controlled matched-pair cohort study of laparoscopic Roux-en-Y gastric bypass and Lap-Band patients in a single US center with three-year follow-up.

Background: Open or laparoscopic Roux-en-Y gastric bypass (RYGBP) is the most common operation for treatment of morbid obesity in USA. The laparoscopic adjustable gastric band (LAGB) has been the most common bariatric operation performed worldwide. The LapBand® was approved for use in USA in July 2001. Since then, several US surgeons have adopted one procedure preferentially over the other, and several have reported patient outcomes. We added the option of the LAGB to the RYGBP in our practice in July 2001. We hypothesized that both procedures will provide similar weight loss and co-morbidity reduction if followed for a sufficient length of time. To enhance weight loss, we adopted a patient behavioral program that is easy to remember, in an attempt to ensure a reduction in caloric intake and reduce hunger regardless of the operation performed. Methods: A case-controlled matched-pair cohort study was conducted. All patients who presented to the Surgical Weight Control Center of Las Vegas between Aug 2001 and Aug 2004 for LAGB were placed into one group, and a matched-pair RYGBP cohort group was created. Patients in the RYGBP cohort were matched for age, sex, date of surgery, and BMI. All patients were evaluated on an intention to treat basis. Data were collected prospectively and analyzed retrospectively. All patients were subjected to the same preoperative education regarding calorie reduction behaviors and diet change, and received the same postoperative counseling regarding long-term eating behavior and food choices. Results: During this period, 208 patients underwent LAGB and 600 underwent RYGBP. Of the 208 LAGB patients, 181 had suitable open or laparoscopic RYGBP matches. The two groups were similar in terms of age, sex, BMI, and co-morbidities. There were no deaths in either group. Resolution of co-morbidities statistically favored RYGBP as did the weight loss, over the study period. Conclusion: When patients are matched with 3-year follow-up according to time of surgery, age, sex and BMI, LRYGBP provides superior weight and co-morbidity reduction and can be done without severe complications. However, the LAGB is an effective weight loss tool and not every patient wishes to have the LRYGBP.

Effect of surgically-induced weight loss on leukocyte indicators of chronic inflammation in morbid obesity.

Background: Recent evidence suggests that morbid obesity is a chronic inflammatory condition that may be associated with immune dysfunction.To test this hypothesis, we investigated several leukocyte cell surface markers of chronic inflammation and followed their response to surgically-induced weight loss. Methods: 26 patients having Roux-en-Y gastric bypass (RYGBP) for morbid obesity (BMI>40) were compared to 10 normal controls (BMI<25). Relative monocyte and neutrophil frequencies and expression of the activation antigens CD11b (adhesion molecule), CD16 (Fc receptor), and CD62L (Lselectin), were evaluated by flow cytometry preoperatively and at 1, 3, 6 and 12 months after RYGBP. Cases served as their own controls but were also compared to non-obese controls. The results were statistically analyzed using Students t-test and ANOVA for parametric values and Mann-Whitney along with Kruskal-Wallis ANOVA for nonparametric values Results: The control group had mean age 37 ± 7.6 with mean 23 ± 2.5 and no comorbidities. The mean age of the sample group was 40.36 ± 13.7 with mean BMI 52 ± 8.2. The neutrophil and monocyte relative frequencies of CD11b (monocytes and neutrophils), and CD16 (neutrophils only) were comparable to controls at baseline and did not change significantly with weight loss throughout the study period. However, a significant reduction of CD62L (Lselectin) expression was noted in monocytes and neutrophils at baseline (neutrophils 103 vs 240 gmf, p<0.001) (monocytes104 vs 246 gmf, P<0.001) when compared to normal controls. Levels of L-selectin normalized by 6 months in both monocytes and neutrophils, and by 12 months had become abnormally elevated in monocytes (monocytes 391 gmf, P=0.007); in neutrophils, there was an upward trend that did not reach significance.The expression of the LPS receptor CD14 in the study group was elevated significantly compared to controls at baseline (1129 vs 719 gmf, P=0.004); this marker appeared to return to normal by 3 months. Monocyte CD14+/CD16+ subset percentage were also elevated significantly at baseline (14.3% vs 5.25%, P <0.001), declined throughout the time period but was still significant at 1 year (8.8%, P<0.001). Eosinophil percentages were elevated at baseline (3.3% obese vs 1.8% controls, P=0.003) and remained so throughout the time period. Conclusion: Deficiencies in the immune system of morbidly obese individuals include elevated levels of eosinophils, monocyte CD14, and monocyte CD14+/CD16+ subsets, with depression of monocyte and neutrophil CD62L. These abnormal levels reverse rapidly with surgically-induced weight loss. RYGBP is not only a weight loss operation but also appears to be an immune restorative procedure.

Preperitoneal Herniation Into a Laparoscopic Port Site Without a Fascial Defect

Background: Port site herniation is an uncommon event that usually occurs as a result of incomplete fascial closure. This allows the omentum or viscera to herniate through the incompletely closed defect. However, in laparoscopic surgery for morbid obesity, the omentum and viscera can herniate through the thick preperitoneal space even with a complete closure of the fascia. Case Report: A 19-year-old female with BMI 55 underwent uneventful long limb laparoscopic Roux-en-Y gastric bypass. On postoperative day 1 the patient had limited pain, was ambulating well, and was tolerating sips of liquids. A limited upper GI series performed on postoperative day 2 revealed no leak or obstruction. Several hours later the patient developed abdominal pain associated with nausea, which progressed to vomiting. CT of the abdomen suggested a port site herniation into the left subcostal port. The cause of the obstruction appeared to be herniation through the left subcostal port site. At laparotomy, a segment of bowel just distal to the anastomosis was found herniated through the port site. The Richters hernia was reduced. Careful inspection of the fascia revealed a complete fascial closure, with the strangulated portion of the bowel incarcerated in the preperitoneal space. Following repair of the preperitoneal defect, her subsequent recovery was unremarkable. Conclusion: Laparoscopic surgery for morbid obesity presents the possibility for preperitoneal herniation. Closure, using a fascial closure device, under laparoscopic control, may offer a solution by closing both the fascia and peritoneum all at once.

Dysfunctional Immune-Privilege In Morbid Obesity: Implications and Effect of Gastric Bypass Surgery

Background: Despite the epidemiological evidence linking obesity and cancer, there has never been a causal link.We believe the chronic inflammation present in obesity may predispose the obese to cancer through Fas-receptor over-expression and L-selectin under-expression in leukocytes, and elevated Fas ligand secretion in tumors affecting the morbidly obese. Methods: Leukocytes from 25 patients having gastric bypass surgery were compared to 15 normal controls preoperatively and at 1, 3, 6, and 12 months postoperatively using flow cytometry to measure CD3, CD4, CD8, CD56, CD62 (L-selectin), CD 69, and CD95 (Fas antigen) expression on T lymphocytes, B lymphocytes, natural killer cells, and neutrophils. Results: The percentage of CD95+T cells was significantly elevated from controls (69.4% vs 56%, P=0.005). This difference persisted through 1 month postoperatively. Furthermore, expression of CD95 per cell, was significantly greater in these patients than that of the controls (80.2 vs 62.6 gmf, P=0.018) preoperatively, and this continued to 1 month. Polymorphonuclear cells also displayed a similar elevation in CD95 gmf expression preoperatively (54.1 vs 40.7 gmf, P=0.023) which normalized by 3 months. Natural killer cells did not display elevated numbers of CD95 gmf preoperatively, but they did experience a significant decline by 12 months. Additionally, there was significant reduction in the number of naiveT cells [(T cells without L-selectin (CD62L)], when compared to normals preoperatively (41.8% vs 51.3%, P=0.001). There was no statistical difference between the postoperative patients and the controls by 3 months. CD69 was not different at baseline from controls in T or B cells, but there was a significant decrease by 12 months. Conclusion: The reduced expression of L-selectin combined with the elevated levels of CD95 suggests that morbid obesity predisposes patients to sites of immune privilege. This could be the mechanism for increased rates of cancer and wound infections seen in obesity. Surgically-induced weight loss eliminates these risk factors.

The Effect of Obesity on Neutrophil Fc Receptors and Adhesion Molecules (CD16, CD11b, CD62L)

Background: There is a large body of epidemiological data associating obesity with a wide variety of clinical disease processes, including cancer and wound infections. However, defining the specific defects of neutrophils has proved difficult and often contradictory. Methods: 27 patients having gastric bypass surgery for obesity (BMI>40) were compared with 10 normal controls (BMI<26). Relative neutrophil frequencies and expression of the activation antigens CD11b (integrin adhesion molecule), CD16 (Fc receptor), and CD62L (L- selectin), were evaluated by flow cytometry. Results: The study control group had a mean age of 37 ± 7.6 yrs (range 30 to 57) with no significant health problems.Their mean BMI was 23 ± 2.5 kg/m2 (range 21-26). The mean age of the sample group was 40.36 ± 13.7 yrs (range 18 to 60) with a mean BMI of 52 ± 8.2 kg/m2 (range 41 to 72).These patients had a large spectrum of diseases that afflict the morbidly obese, including hypertension (14), arthritis (10), exertional dyspnea (13), venous stasis (7), hypothyroidism (2), NIDDM (3), heart murmur (1), along with 8 smokers. The neutrophil frequency in the obese patients was comparable to the controls (control 49% vs obese 51%). Additionally, there was no apparent difference between obese and controls regarding CD11b or CD16 expression (424 vs 498 gmf) (267 vs 262 gmf). However, there was a significant reduction of CD62L (L-selectin) expression noted in the morbidly obese with respect to controls (102 vs 303 gmf, p<0.001). An increased percentage of eosinophils when compared to controls (6.7% vs 1.73%, p<0.001) was also observed. Conclusion: Discordant CD11b/CD62L levels, depressed levels of CD62L, and elevated eosinophil percentages support the hypothesis that a chronic inflammatory state exists in morbid obesity. Decreased levels of CD62L in the morbidly obese neutrophil pool possibly affect the neutrophils ability to activate and migrate to sites of inflammation. This may play a role in the higher incidence of infectious complications seen in morbidly obese individuals.

Lower Extremity Compartment Syndrome Following a Laparoscopic Roux-en-Y Gastric Bypass.

Background: Bariatric surgery has the potential for serious complications. A case is presented of unilateral lower extremity compartment syndrome after a laparoscopic Roux-en-Y gastric bypass performed in the modified lithotomy position. Case report: A 38-year-old female (weight 134.5 kg, BMI 49.6) underwent a laparoscopic Roux-en-Y gastric bypass (operating time 375 min). Postoperatively, she complained of bilateral lower extremity pain that gradually subsided over the course of the day. However, on the 1st postoperative day she developed numbness on the dorsum of the foot and compartment syndrome was diagnosed (anterior compartment pressure 71 mmHg). She underwent emergency fasciotomy,which resulted in a reduction of the pain and numbness on the dorsum of the foot. The next day she ambulated without difficulty and was discharged home on the 5th postoperative day. 12 days after her operation, delayed primary closure of the fasciotomy wound was done with the assistance of a novel device (Proxiderm) that applies constant tension to the wound edges. Subsequent recovery was uneventful, and at 4- month follow-up the patient had a weight loss of 28 kg without any right leg motor or sensory deficits. Conclusion: Bariatric surgeons should be aware of compartment syndrome as a rare but serious complication. Prevention, early recognition, and prompt fasciotomy are crucial for a favorable outcome.

DRG, Costs and Reimbursement following Roux-en-Y Gastric Bypass: an Economic Appraisal

Background: There is disagreement regarding hospital and physician reimbursement fees when DRG codes are used. We have found that physicians and hospitals are rewarded differently depending on the type of insurance coverage - per diem HMO (Health Maintenance Organization) vs public. Methods: 133 patients were retrospectively analyzed in a single institution. There were 59 privately-insured and 74 publicly-insured patients. Using DRG 288, hospital and surgeon reimbursement rates, complications, length of stay, blood loss and basic demographics were evaluated on all patients. Reimbursement rates were then compared to inpatient hospital costs per case for both open and laparoscopic Roux-en-Y gastric bypass (RYGBP). Statistical analysis used Students t-test and standard deviation. Results: The 2 groups were similar in terms of age, sex and BMI. There was a large difference in physician reimbursement when comparing public to private insurance (

The mini-fellowship concept: a six-week focused training program for minimally invasive bariatric surgery

931±73 vs

Internal hernia after revisional laparoscopic loop duodenal switch surgery.

2356±822, P<0.001). Likewise, there was a large difference in hospital reimbursement (public

Tumor growth factor expression in obesity and changes in expression with weight loss: another cause of increased virulence and incidence of cancer in obesity

11773 ± 4462 vs private