Francesco Greco

The laparoscopic mini-gastric bypass: the Italian experience: outcomes from 974 consecutive cases in a multicenter review

AbstractBackgroundDue to the failure of the “old Mason loop,” the mini-gastric bypass (MGB) has been viewed with skepticism. During the past 12xa0years, a growing number of authors from around the world have continued to report excellent short- and long-term results with MGB.MethodsOne university center, three regional hospitals, and two private hospitals participated in this study. From July 2006 to December 2012, 475 men (48.8xa0%) and 499 women (51.2xa0%) underwent 974 laparoscopic MGBs. The mean age of these patients was 39.4, and their preoperative body mass index was 48xa0±xa04.58xa0kg/m2. Type 2 diabetes mellitus (T2DM) affected 224 (22.9xa0%) of the 974 patients, whereas 291 of the 974 patients (29.8xa0%) presented with hypertension. The preoperative gastrointestinal status was explored in all the patients through esophagogastroduodenoscopia. The major end points of the study were definitions of both MGB safety and efficacy in the long term as well as the endoscopic changes in symptomatic patients eventually produced by surgery.ResultsThe rate of conversion to open surgery was 1.2xa0% (12/974), and the mortality rate was 0.2xa0% (2/974). The perioperative morbidity rate was 5.5xa0% (54/974), with 20 (2xa0%) of the 974 patients requiring an early surgical revision. The mean hospital length of stay was 4.0xa0±xa01.7xa0days. At this writing, 818 patients are being followed up. Late complications have affected 74 (9xa0%) of the 818 patients. The majority of these complications (66/74, 89.1xa0%) have occurred within 1xa0year after surgery. Bile reflux gastritis was symptomatic, with endoscopic findings reported for 8 (0.9xa0%) and acid peptic ulcers for 14 (1.7xa0%) of the 818 patients. A late revision surgery was required for 7 (0.8xa0%) of the 818 patients. No patient required revision surgery due to biliary gastritis. At 60xa0months, the percentage of excess weight loss was 77xa0±xa05.1xa0%, the T2DM remission was 84.4xa0%, and the resolution of hypertension was 87.5xa0%.ConclusionsDespite initial skepticism, this study, together with many other large-scale, long-term similar studies from around the world (e.g., Taiwan, United States, France, Spain, India, Lebanon) demonstrated the MGB to be a short, simple, low-risk, effective, and durable bariatric procedure.n

Modifications of Metabolic and Cardiovascular Risk Factors after Weight Loss Induced by Laparoscopic Gastric Banding

Background: The well-known inverse relation between life expectancy and BMI, particularly in morbid obesity, is presumably in large part due to multiple cardiovascular and metabolic comorbidities. Severely obese patients treated with laparoscopic adjustable silicone gastric banding (LASGB) were evaluated for such risk factors before and 1 year after LASGB. Methods: 130 individuals (age 20-66, BMI 34-59 kg/m2) who underwent LASGB between 1996 and 2000 were studied; 50 of them were available for reevaluation 12 months after surgery. The presence and severity of diabetes (DM), hypertension (HTN), hypercholesterolemia (HC) and hypertriglyceridemia (HT) were assessed before and after surgery. In 18 of them erythrocyte sedimentation rate (ESR) were also measured. Results: Comorbidities were highly prevalent at the initial evaluation: DM 10%, HTN 32%, HC 37%, HT 27%. In the subgroup reevaluated after surgery, prevalence of DM decreased from 15% to 6%, HTN from 37% to 25%, HC from 36% to 25%, and HT from 29% to 13%, with an average BMI loss from 44.1 to 35.9. ESR decreased from a preoperative value of 36.7 ± 22.6 mm/hr to 18.3 ± 11.9 mm/hr at 1 year (p < 0.001). Conclusion: Morbidly obese subjects respond to LASGB with an impressive reduction of comorbidities which is sustained for at least 1 year, well after the initial acute negative energy balance and when weight tends to stabilize. The high prevalence of elevated ESR, which has been considered a strong predictor of coronary mortality, confirms previous reports of its association with obesity, and the clear tendency to normalization with weight loss may represent a further element contributing to lower morbidity.

Efficacy of Bariatric Surgery in Type 2 Diabetes Mellitus Remission: the Role of Mini Gastric Bypass/One Anastomosis Gastric Bypass and Sleeve Gastrectomy at 1 Year of Follow-up. A European survey

BackgroundA retrospective study was undertaken to define the efficacy of both mini gastric bypass or one anastomosis gastric bypass (MGB/OAGB) and sleeve gastrectomy (SG) in type 2 diabetes mellitus (T2DM) remission in morbidly obese patients (pts).MethodsEight European centers were involved in this survey. T2DM was preoperatively diagnosed in 313/3252 pts (9.62xa0%). In 175/313 patients, 55.9xa0% underwent MGB/OAGB, while in 138/313 patients, 44.1xa0% received SG between January 2006 and December 2014.ResultsTwo hundred six out of 313 (63.7xa0%) pts reached 1xa0year of follow-up. The mean body mass index (BMI) for MGB/OAGB pts was 33.1u2009±u20096.6, and the mean BMI for SG pts was 35.9u2009±u20095.9 (pu2009<u20090.001). Eighty-two out of 96 (85.4xa0%) MGB/OAGB pts vs. 67/110 (60.9xa0%) SG pts are in remission (pu2009<u20090.001). No correlation was found in the % change vs. baseline values for hemoglobin A1c (HbA1c) and fasting plasma glucose (FPG) in relation to BMI reduction, for both MGB/OAGB or SG (ΔFPG 0.7 and ΔHbA1c 0.4 for MGB/OAGB; ΔFPG 0.7 and ΔHbA1c 0.1 for SG). At multivariate analysis, high baseline HbA1c [odds ratio (OR)u2009=u20090.623, 95xa0% confidence interval (CI) 0.419–0.925, pu2009=u20090.01], preoperative consumption of insulin or oral antidiabetic agents (ORu2009=u20090.256, 95xa0% CI 0.137–0.478, pu2009=u2009<0.001), and T2DM duration >10xa0years (ORu2009=u20090.752, 95xa0% CI 0.512–0.976, pu2009=u20090.01) were negative predictors whereas MGB/OAGB resulted as a positive predictor (ORu2009=u20093.888, 95xa0% CI 1.654–9.143, pu2009=u20090.002) of diabetes remission.ConclusionsA significant BMI decrease and T2DM remission unrelated from weight loss were recorded for both procedures if compared to baseline values. At univariate and multivariate analyses, MGB/OAGB seems to outperform significantly SG. Four independent variables able to influence T2DM remission at 12xa0months have been identified.

Prevalence of Cancer in Italian Obese Patients Referred for Bariatric Surgery

Background: An association between obesity and cancer has been shown in large epidemiological studies. The aim of this study was to evaluate the prevalence and types of malignancies in an Italian cohort of obese patients referred to a bariatric center. Methods: A retrospective, observational study was conducted. Between Jan 1996 and Dec 2004, 1,333 obese patients (M=369, F=964) were seen in the center for minimally invasive treatment of morbid obesity. Morbid obesity were considered as BMI >40 kg/m2 or BMI >35 kg/m2 with at least one co-morbidity. Obese and morbidly obese patients who suffered any form of cancer were reviewed. Results: 43 patients (3.2%) presented various malignancies, with 88.3% in females. The prevalence of cancer in the younger group (21-46 years) was higher than in the older group (47-70 years), 2.1% vs 1.1%. 26 obese patients out of the 43 (60.5%) (age 41±7.9 years, BMI 38.2±9.9) presented hormone-related tumors. The most frequent site of cancer was breast (20.9%), followed closely by thyroid. Conclusion: This is the first Italian report on prevalence of cancer in a homogeneous obese population attending an academic bariatric center. The morbidly obese patients appear to have a higher risk of developing cancer, with a higher prevalence of hormone-related tumors. The predominant gender affected by both obesity and cancer was female. Thus, a preoperative work-up for cancer screening is indicated in this group of patients.

Results after Laparoscopic Adjustable Gastric Banding in Patients Over 55 Years of Age

Background: Laparoscopic adjustable gastric banding (LAGB) has become the most popular bariatric intervention in Europe. International guidelines recommended age limits for bariatric surgery of 18-60 years. The aim of this study was to evaluate the immediate results in morbidly obese patients >55 years old, treated with LAGB. Methods: Between January 1996 and January 2004, 350 patients underwent LAGB. 24 (6.8%) were >55 years old (Group A), mean age 58.6±3.3 years, mean preoperative BMI 42.3±4.5 kg/m2. A comparative randomized analysis with 24 patients younger than age 55 years was performed (Group B: mean age 41.2±9.6 years, mean BMI 42.1±3.6 kg/m2). Baseline clinical features, operative parameters and postoperative results were evaluated. Results: No perioperative complications were recorded. Conversion rate and mortality were nil. Major postoperative complications occurred in 2 patients (8.3%) from Group A (1 intragastric prosthesis migration, 1 pouch dilatation) and 2 patients (8.3%) from Group B (intragastric migrations). Reoperation was needed in 3 cases, and one erosion (Group B) is on the waiting list for removal. Minor complications: 1 port infection in each group required ambulatory port substitution; 1 intraperitoneal portcatheter disconnection (Group B) was successfully treated laparoscopically. Mean follow-up was 31.7 months (Group A) and 33.0 months (Group B). Mean postoperative BMI at 12 and 24 months was 35.9±4.2 and 33.8±4.9 for Group A, and 33.8±4.6 and 33.2±6.0 for Group B. Conclusion: There have been no significant differences in results between the 2 groups. LAGB has been safe and effective in patients >55 years old.

Laparoscopic sleeve gastrectomy as a revisional procedure for failed laparoscopic gastric banding with a “2-step approach”: a multicenter study

BACKGROUNDnLaparoscopic sleeve gastrectomy (LSG) has been proposed as an alternative revisional procedure for failed/complicated gastric banding. This is a retrospective cohort study of a prospectively maintained database of revisional LSG after band removal for insufficient weight loss and/or band-related complications, using a 2-step approach. The outcomes were compared with a control group of primary LSG. The study was conducted at a university hospital (Sapienza University of Rome-Polo Pontino, Icot, Latina, Italy) and 2 community general hospitals (Hospital Andosilla Civita Castellana, Viterbo, Italy and Hospital Villa DAgri, Potenza, Italy).nnnMETHODSnA total of 76 revisional LSG procedures was recorded; a control group of 279 LSG patients was selected. The primary endpoint was to compare the perioperative complication rate between the revisional versus the control group. Secondary endpoints were operative time, conversion rate, postoperative length of stay and percentage excess weight loss (%EWL) at 6, 12, and 24 months.nnnRESULTSnThe indications for band removal were inadequate weight loss (47 patients), slippage (10 patients), erosion (7 patients), and pouch dilation (12 patients). All procedures were completed laparoscopically. The median operative time was 78 minutes for the revision LSG and 65 minutes for the control LSG (P<.05). In the revision group, the overall complication rate was 17.1%, and the median postoperative length of stay was 4 days; in the control group, the overall complication rate was 10.7%, and the median postoperative length of stay was 3. No complications requiring reoperation or readmission occurred in the revision group. In the control group, there were 5 cases of major complications. All the patients completed the follow-up. A total of 56 patients in the revision group and 184 patients in the control group were followed-up for at least 24 months. The %EWL at 6, 12, and 24 months was 46.5%, 66.4%, and 78.5%, respectively, in the revision group, and 49.8%, 78.2%, and 78%, respectively, in the control group.nnnCONCLUSIONnResults confirmed that LSG, performed in 2 steps, is an effective revision procedure for failed or complicated laparoscopic adjustable gastric banding with good perioperative outcomes and 2-year weight loss.

Complications Following the Mini/One Anastomosis Gastric Bypass (MGB/OAGB): a Multi-institutional Survey on 2678 Patients with a Mid-term (5 Years) Follow-up.

BackgroundIn recent years, several articles have reported considerable results with the Mini/One Anastomosis Gastric Bypass (MGB/OAGB) in terms of both weight loss and resolution of comorbidities. Despite those positive reports, some controversies still limit the widespread acceptance of this procedure. Therefore, a multicenter retrospective study, with the aim to investigate complications following this procedure, has been designed.Patients and MethodsTo report the complications rate following the MGB/OAGB and their management, and to assess the role of this approach in determining eventual complications related especially to the loop reconstruction, in the early and late postoperative periods, the clinical records of 2678 patients who underwent MGB/OAGB between 2006 and 2015 have been studied.ResultsIntraoperative and early complications rates were 0.5 and 3.1%, respectively. Follow-up at 5xa0years was 62.6%. Late complications rate was 10.1%. A statistical correlation was found for perioperative bleeding both with operative time (pxa0<xa00.001) or a learning curve of less than 50 cases (pxa0<xa00.001). A statistical correlation was found for postoperative duodenal-gastro-esophageal reflux (DGER) with a preexisting gastro-esophageal-reflux disease (GERD) or with a gastric pouch shorter than 9xa0cm, (pxa0<xa00.001 and pxa0=xa00.001), respectively. An excessive weight loss correlated with a biliopancreatic limb longer than 250xa0cm (pxa0<xa00.001).ConclusionsOur results confirm MGB/OAGB to be a reliable bariatric procedure. According to other large and long-term published series, MGB/OAGB seems to compare very favorably, in terms of complication rate, with two mainstream procedures as standard Roux-en-Y gastric bypass (RYGBP) and laparoscopic sleeve gastrectomy (LSG).

Conversion of Vertical Sleeve Gastrectomy to a Functional Single-Anastomosis Gastric Bypass: Technique and Preliminary Results Using a Non-Adjustable Ring Instead of Stapled Division

BackgroundRecent data show that some patients will have insufficient weight loss or experience weight regain after sleeve gastrectomy. Dilation of the sleeve over time or use of an inadequate technique may contribute to relapse of morbid obesity. Repeat sleeve gastrectomy is the most obvious option but requires stapling of scarred tissue, has a higher risk of leakage, and is prone to re-enlargement with time. We herein describe a simple and innovative technique with which to revise vertical sleeve gastrectomy (VSG) into functional single-anastomosis gastric bypass (f-SAGB).Materials and MethodsTwelve VSGs were converted to f-SAGB by placing a GaBP Ring (Bariatec Corp., Palos Verdes Peninsula, CA, USA) at the base of the “sleeve” and performing the anastomosis above the ring. The length of the biliopancreatic loop was chosen according to the volume of the pouch and the patient’s residual eating capability.ResultsAll procedures were completed by laparoscopy and were uneventful. The average decrease in the body mass index was from 41.0 to 29.5xa0kg/m2 at the 12-month follow-up. No ring-related complications were reported.Conclusionf-SAGB is a low-risk and effective option with which to revise VSG in patients with inadequate weight loss. Avoiding detachment of the pouch from the antrum assures full reversibility of the procedure and preserves the chance to explore the remnant stomach and biliary tree.

Ileal Food Diversion: a Simple, Powerful and Easily Revisable and Reversible Single-Anastomosis Gastric Bypass

BackgroundMalabsorptive interventions are recognized as procedure of choice in metabolic surgery and the best strategy for re-do surgery when restriction failed. We describe a novel procedure, the ileal food diversion, an easy and effective non-restrictive one-anastomosis gastric bypass.MethodsWe report the preliminary results of a series of 68 consecutive patients performed by two surgeons in two different hospitals since 2009 (49 females, 13 re-do surgeries).ResultsMean operating time was 65xa0min. All operations were performed by laparoscopy (three-trocar technique in 44 cases and 24 single-incision laparoscopies). Median follow-up is 9.6xa0months (range 2–48). Diabetes resolution was accomplished in 80xa0% of patients. Average BMI decreases from 44 to 27 after 24xa0months.ConclusionsIleal food diversion is an interesting option in super-obese patients, re-do surgery and patients with metabolic syndrome. Technical considerations, physiological assumptions and rationale were discussed.

Short-term outcomes of sleeve gastrectomy conversion to R-Y gastric bypass: multi-center retrospective study

IntroductionThe outcomes of failed laparoscopic sleeve gastrectomies (LSG) converted to laparoscopic standard R-Y gastric bypass (LRYGB) in case of insufficient weight loss (IWL), weight regain (WR), and/or severe gastro-esophageal reflux disease (GERD) are scanty.PurposeTo evaluate incidence, indications, and short-term outcomes of LSG conversion to LRYGB in three bariatric centers.MethodsPatients operated between January 2012 and December 2016 by primary LSG, with mean follow-up of 24xa0months and converted to LRYGB for IWL, WR, and/or GERD, were retrospectively analyzed for demographics, operative details, perioperative complications, comorbidities evolution, and further WL.ResultsThirty patients (2.76%, 7 M/23 F, mean age 41u2009±u200910.1xa0years, initial mean BMI 46.9u2009±u20096.3xa0kg/m2) were successfully converted after a mean period of 33u2009±u200927.8xa0months for severe GERD (15 patients, 50%), GERD and IWL/WR (3 patients, 10%), and IWL/WR (12 patients, 40%). Surgical complications occurred in three patients (10%). Mean BMI at revision time was 36u2009±u20099xa0kg/m2, and 30.8u2009±u20095.2, 28u2009±u20094.9, and 28u2009±u20094.3xa0kg/m2 after 6, 12, and 24xa0months, respectively. Resolution of GERD was achieved in 83% of cases. Overall, postoperative satisfaction was reported by 96% of the cases, after mean follow-up of 24u2009±u20098.9xa0months.ConclusionsIn high-volume centers, where strict criteria for patients’ selection for LSG are applied, the expected incidence of reoperations for “non-responder” (IWL/WR) or de novo or persistent severe GERD non-responder to medical treatment is low (<u20093%). Conversion of “non-responder” LSG to LRYGB is effective for further WL and GERD remission at short term (2xa0years follow-up); however, a high postoperative complication rate was observed. Long-term multidisciplinary follow-up is mandatory to confirm data on WL durability and comorbidity control.