Enrico Mozzi

An Unusual Complication of Gastric Banding: Recurrent Small Bowel Obstruction Caused by the Connecting Tube

Laparoscopic adjustable gastric banding (LAGB) is a widely performed surgical procedure for morbid obesity. The application of this mini-invasive approach has given the benefits of shorter hospital stay, less postoperative pain and quicker functional recovery. LAGB complications are related either to the access-port, such as port-site infection or tubing disconnection, or to the band, such as band slippage, pouch dilatation, or intragastric migration. We report a case of recurrent small bowel obstruction caused by the connecting tube around a jejunal loop, in a woman who had under-gone LAGB 3 years before. The diagnosis was difficult to establish because the clinical history and examination were non-specific. A 3-dimensional CT scan was needed to explain the cause of the recurrent abdominal pain, and the small bowel loop was freed from the connecting tube at laparoscopy.

Prevention of Pouch Dilatation after Laparoscopic Adjustable Gastric Banding

Background: The major long-term complication of laparoscopic adjustable gastric banding (LAGB) is dilatation of the gastric pouch, that is reported with a frequency ranging from 1 to 25%, and often requires removal of the band. In addition to the usual recommendations of bariatric surgery centers and dietetic advice to prevent this complication, over the last 4 years we introduced a technical modification of the procedure. Methods: From Nov 1993 to Dec 2004, 684 morbidly obese patients underwent adjustable gastric banding, 83 patients by open surgery and 601 patients by laparoscopy. The first 323 patients (group A) were operated by the perigastric approach, and 57 patients (group B) were operated by the pars flaccida approach. Since Dec 2000, 304 patients (group C) were operated with a modified pars flaccida technique, which consisted in suturing the gastric lesser curvature below the band with one or two stitches to the right phrenic crus to secure the band in place. Results: In group A, the most important late complication was irreversible dilatation of the gastric pouch, which occurred in 35 patients (10.8%), and required removal of the band in 30 cases and replacement in 5. In group B, there were 3 pouch dilatations (5.2%). In group C, only 4 dilatations occurred (1.31%), which required 3 band removals and 1 band replacement. Conclusion: Dilatation of the gastric pouch appears to be dramatically reduced by our minor technical modification of band placement.

Improvement in health-related quality of life in first year after laparoscopic adjustable gastric banding

BACKGROUND We analyzed the health-related quality of life (HRQOL) and its determinants in the first year after laparoscopic adjustable gastric banding (LAGB). The setting was 10 Italian public and private bariatric surgery centers. METHODS Data collected in an ongoing, prospective, 3-year multicenter Italian study on the changes in HRQOL after LAGB were used. HRQOL was investigated using the Medical Outcomes Study Short-Form 36 questionnaire. Hunger, satiety, and the self-perceived effects of LAGB were recorded. RESULTS A total of 334 patients were enrolled. The follow-up rate was 92.2%. The percentage of excess weight loss was 39.6% ± 25.8%, with very few side effects or complications. Hunger in the morning (0-10 scale) was 4.5 ± 2.7 before surgery and 3.8 ± 2.4 after 1 year (P <.001). Satiety after a meal (0-10 scale) was 7.1 ± 2.7 before surgery and 8.2 ± 1.9 at 1 year (P <.001). The self-perceived effect of LAGB on caloric intake (0-10 scale) was 8.4 ± 1.9 after 1 year. The scores for the 8 Medical Outcomes Study Short-Form 36 subscales were significantly improved after surgery. The physical component summary score was 52.6 ± 11.9 at baseline and 79.1 ± 15.6 after 1 year (P <.001). The corresponding mental component summary scores were 52.2 ± 12.3 and 76.5 ± 17.2 (P <.001). Greater physical component summary improvement was independently associated with a low initial physical component summary (P <.001), high satiety (P = .002), a high percentage of excess weight loss (P = .013), and a high self-perceived effect of the LAGB (P = .026). Greater mental component summary improvement was associated with a low initial mental component summary (P <.001), high satiety (P <.001), a low frequency of heartburn (P = .004), and a high percentage of excess weight loss (P = .012). CONCLUSIONS Significant improvements in HRQOL were observed in the first year after LAGB. A poor baseline HRQOL, a high efficacy of the banding in eating control, and better weight loss might influence HRQOL changes.

Histologic Study of Tissue Reaction to the Gastric Band: Does it Contribute to the Problem of Band Erosion?

Background: One of the major complications of gastric banding is intragastric migration of the band. The frequency ranges from 0.5% to 3.8%, and removal of the band is always required. We undertook a prospective study with the aim to determine the reasons for this significant complication in bariatric surgery. Methods: 480 morbidly obese patients underwent adjustable gastric banding in our Surgical Department, from February 1998 to October 2005. 31 of them were reoperated for different surgical problems, at an average time of 39 months after the bariatric procedure. During the reoperation, some fragments of fibro-adipose tissue in close contact with the band were removed. They were examined, focusing on the following parameters: acute and chronic inflammation, fibrosclerosis, and foreign body granulomatous reaction. Results: Histological assessment showed the presence of acute and chronic inflammation, generally of mild and medium grade; fibrosclerosis was present mostly in a severe form, indicating a biological periprosthesic wall that separates and protects the gastric wall from the band; no cases of foreign body reaction were observed, nor were silicone inclusions found inside the inflammatory cells. Conclusion: The histologic changes of periprosthesic tissue do not appear to account for endoluminal migration of the gastric band. Thus, band erosion could have a closer correlation with other causes, such as infection of the band or intraoperative surgical damage, possibly due to direct mechanical action or to the thermal effect of the electric scalpel.

Impact of the metabolic syndrome on subcutaneous microcirculation in obese patients.

Objectives Patients with the metabolic syndrome are at increased cardiovascular risk and display an augmented wall stiffness of the large-sized and medium-sized arteries, coupled with an endothelial dysfunction. Whether this is the case also for the small resistance arteries is unknown, however. It is also unknown whether and to what extent the hypothesized microvascular alterations are greater for magnitude than the ones characterizing obesity, that is the most common component of the metabolic syndrome. Methods In 14 lean healthy controls (age 48.7 ± 2.4 years, mean ± SEM), 13 obese participants and 12 individuals with the metabolic syndrome (Adult Treatment Panel III criteria), all age-matched with healthy controls, we assessed the small resistance arteries dissected from the abdominal subcutaneous tissue on a pressurized myograph. Results The media thickness, media cross-sectional area (CSA) and media-to-lumen ratio (M/L) of the small resistance arteries were markedly and significantly greater in metabolic syndrome than in controls (media thickness: 28.3 ± 0.7 vs. 17.5 ± 0.3 μm; CSA: 24 760.8 ± 1459 vs. 16 170.7 ± 843.6 μm2 and M/L: 0.12 ± 0.01 vs. 0.064 ± 0.002 a.u., respectively, P < 0.01 for all). Acetylcholine-induced relaxation was impaired in the vessels from metabolic syndrome participants compared with the lean healthy individuals (−48.8%, P < 0.01), whereas endothelium-independent vasorelaxation was similar in the two groups. The structural and functional microvascular alterations seen in metabolic syndrome were slightly, although not significantly, greater than the ones seen in uncomplicated obese participants. Stiffness of small arteries, as assessed by the stress/strain relationship, was also similar in the three groups of participants. Conclusion Thus, metabolic syndrome is characterized by marked alterations in the structural and functional patterns of the small resistance arteries. These alterations, which are only slightly greater than the ones seen in obesity, may be responsible for the increased incidence of coronary and cerebrovascular events reported in metabolic syndrome.

Three years durability of the improvements in health-related quality of life observed after gastric banding

BACKGROUND Improvements in health-related quality of life (HR-QoL) occur after bariatric surgery. However, sustainability of these changes over time remains debated. METHODS Data collected in a prospective 3-year multicenter Italian study on changes of HR-QoL after laparoscopic adjustable gastric banding were used. HR-QoL has investigated with the SF-36 questionnaire. Hunger, satiety, and the self-perceived effects of LAGB were recorded. RESULTS A total of 230 patients (53 male and 177 female) were analyzed. Body mass index was 41.4±5.4 kg/m2 at baseline, declined to 33.8±5.8 kg/m2 12 months after surgery (P<.001), and further reduced to 31.9±5.1 kg/m2 36 months after surgery (P<.001 versus 12 months). Scores in the SF-36 subscales were lower than in the general Italian population at baseline. The physical component summary score was 51.9±11.6 at baseline, improved to 79.2±15.4 at 12 months (P<.001), and stabilized to 79.8±15.6 at 36 months. The mental summary score was 52.3±11.8 at baseline, improved to 75.2±17.3 at 12 months (P<.001), and stabilized to 74.2±17.5 at 36 months. A decline>10 points between 12 and 36 months in the summary scores was observed in 22.0% of the patients for PCS and in 26.8% for MCS. In a multiple linear regression analysis, deterioration in HR-QoL in the 12-36 months period was associated to the presence of better HR-QoL values at 12 months and to a more pronounced reduction of the self-perceived effect of the banding at 36 months. CONCLUSION Improvements in HR-QoL observed in the first year after surgery maintained up to the third year after gastric banding.

Determinants of health-related quality of life in morbid obese candidates to gastric banding

OBJECTIVE: To analyse determinants of self reported health-related quality of life (HR-QoL) in morbid obese patients candidates to laparoscopic adjustable gastric banding (LAGB). METHODS: Determinants of HR-QoL were investigated in 383 morbid obese patients (82 M and 301 F) with BMI=40 kg/m2 (BMI=35 kg/m2 if complicated obesity) and age 18–60 years. HR-QoL was determined with the SF-36 questionnaire. Determinants of the two summary measures of SF-36 (physical component and mental component) were analysed by stepwise multiple linear regression analysis with age, BMI, physical comorbidites, mental comorbidites and eating behaviour disorders as independent variables. Physical comorbities (diabetes, hypertension, hypertriglyceridemia, low HDL, sleep apnea and osteoarthritis) were coded as present or absent on the basis of simple diagnostic clinical criteria; mental comorbidities (depression) and eating behaviour disorders (binge eating, sweet eating and nibbling) on the basis of an unstructured clinical interview. RESULTS: Mean age was 38.8±10.2 years and mean BMI was 41.5±5.4 kg/m2. Scores in the eight SF-36 subscales were lower in women than in men and lower than in the general Italian population. However, 18.4–43.5% of the participants had HR-QoL levels above the normative values, depending on the scale. In both genders, low scores in the mental component of the SF-36 were associated to the presence of depression and eating behaviour disorders and not to physical comorbidities or BMI levels. Low physical self-perceived well being was associated to high BMI levels in men and to depression, hypertension and hypertriglyceridemia in women. CONCLUSION: HR-QoL was poor in morbid obese candidates to LAGB, particularly in women, and was negatively affected more by mental comorbidites and eating behaviour disorders than by physical comorbidities or BMI levels.

Tratti psichiatrici pre- e post-intervento: studio di un campione di pazienti affetti da grave obesità sottoposti a bendaggio gastrico regolabile

AIM This study identifies psychological features and the evolution of psychiatric symptoms in a group of patients affected by obesity, who underwent adjustable gastric banding. MATERIALS AND METHODS In this group, other than clinical visit, test SCL-90 is made in preoperative time. In postoperative SCL-90, TAS and BES were carried out. Patients evaluated before and after bariatric surgery were 220 and 115, respectively. SCL-90 test made before bariatric surgery showed high values (>0.7) for cluster related to somatization, interpersonal sensitivity, paranoid ideation, depression and obsessive compulsive disorder. DISCUSSION Depression symptoms were more important in patients undergoing endogastric balloon placement (mean value of 0.9). Anxious symptoms showed a mean value of 0.73 in patients undergoing endogastric balloon placement as compared to a mean value of 0.52 in patients undergoing gastric banding. CONCLUSIONS Our findings show that in patients undergoing bariatric surgery, depressive symptoms are more common preoperatively and normalize at follow-up. This confirms that a possible cause of depression is obesity. The present study also shows that anxious symptoms are lower in obese patients.AIM This study identifies psychological features and the evolution of psychiatric symptoms in a group of patients affected by obesity, who underwent adjustable gastric banding. MATERIALS AND METHODS In this group, other than clinical visit, test SCL-90 is made in preoperative time. In postoperative SCL-90, TAS and BES were carried out. Patients evaluated before and after bariatric surgery were 220 and 115, respectively. SCL-90 test made before bariatric surgery showed high values (>0.7) for cluster related to somatization, interpersonal sensitivity, paranoid ideation, depression and obsessive compulsive disorder. DISCUSSION Depression symptoms were more important in patients undergoing endogastric balloon placement (mean value of 0.9). Anxious symptoms showed a mean value of 0.73 in patients undergoing endogastric balloon placement as compared to a mean value of 0.52 in patients undergoing gastric banding. CONCLUSIONS Our findings show that in patients undergoing bariatric surgery, depressive symptoms are more common preoperatively and normalize at follow-up. This confirms that a possible cause of depression is obesity. The present study also shows that anxious symptoms are lower in obese patients.

A Modified Surgical Technique to Prevent Pouch Dilatations after Laparoscopic Adjustable Gastric Banding

Background: Laparoscopic adjustable gastric banding is a widely used and effective procedure for the treatment of morbid obesity, but its major complication, the dilatation of the gastric pouch, is reported with a frequency ranging from 1.5 to 26.3%, and often requires removal of the band. With the aim to prevent this complication, we introduced a modified technique in our clinic, over the last 4 years. Methods: From December 1993 to August 2004, 649 morbidly obese patients underwent adjustable gastric banding (AGB), 83 patients in open surgery and 566 patients laparoscopically. The first 323 patients were operated with the perigatric procedure, and 57 patients were operated with the pars flaccida procedure. Since December 2000, 269 patients were operated with a modified technique of the pars flaccida procedure, which consisted in suturing the lesser gastric curvature with one or two stitches to the right crus. Results: In the first group of 323 patients, the most important late complication was the irreversible dilatation of the upper gastric pouch, which occurred in 35 patients (10.8%), and required removal of the band in 30 cases and replacement in 5 cases. In the second group of 57 patients, there were 3 pouch dilatations (5.2%) which required replacement. In the last 269 patients operated with the new technique, since December 2000, only 4 dilatations occurred (1.48%), which required 3 band removals and 1 band replacement. Conclusions: A technical modification of the usual procedure appears to considerably reduce the major complication of adjustable gastric banding, the dilatation of the gastric pouch.