Franz Aigner

Bariatric Surgery Cannot Prevent Tryptophan Depletion Due to Chronic Immune Activation in Morbidly Obese Patients

Background: Increased activity of the immuno-modulatory enzyme indoleamine-2,3-dioxygenase (IDO) during immune activation, results in tryptophan depletion. Tryptophan metabolic changes reduce serotonin production and cause mood disturbances, depression, and impaired satiety, ultimately leading to increased food intake and obesity. Bariatric surgery significantly diminishes immune mediators by substantial weight reduction. We examined IDO-mediated tryptophan-catabolism in morbidly obese patients compared to lean individuals. Methods: Serum concentrations of kynurenine and tryptophan, calculated kynurenine to tryptophan ratios (kyn trp-1) as an indirect estimate of IDO activity, and neopterin levels reflecting IFN-γ mediated immune activation, were assessed before and after bariatric surgery. The study population included 22 morbidly obese individuals and 20 normal-weight volunteers. Results: Median weight loss after 24.4±5.1 months was 40.6 kg resulting in a reduction of BMI from 44.1 kg/m2 to 29.9 kg/m2 (P<0.001). Preoperative kyn trp-1 in morbidly obese patients was significantly increased compared to the control group (41.6±20.1 mmol/mol vs 26.5±5.1 mmol/mol; P<0.001). Postoperative weight reduction did not lead to normalization of kyn trp-1 (37.9±14.0 mmol/mol). As a consequence, tryptophan levels were significantly lower in morbidly obese patients (pre-: 51.5±9.2 μmol L−1 and postoperatively: 46.9±7.6 μmol L−1) when compared with those of normal-weight controls (64.8±9.5 μmol L−1; P<0.001). In addition, neopterin levels were elevated in the study population pre- and postoperatively compared to normal-weight volunteers (both P<0.001). Conclusions: Tryptophan depletion in morbidly obese patients is due to chronic immune activation and persists in spite of significant weight reduction following bariatric surgery. This might thereby be responsible for diminished serotonin functions, leading to unchanged satiety dysregulation and a reward-deficiency-syndrome.

Results and Complications after Laparoscopic Adjustable Gastric Banding in Super-obese Patients, using the Swedish Band

Background: Laparoscopic adjustable gastric banding is effective in inducing weight loss, as well as being minimally invasive, totally reversible, and adjustable to the patients needs. The aim of this study was to assess the efficacy and safety of adjustable gastric banding with the Swedish band (SAGB) in super-obese patients. Patients and Methods: Between January 1996 and December 2003, 682 patients (570 women, 112 men) underwent SABG implantation. In these patients, there were 60 super-obese patients with a BMI ≥ 50 kg/m2. Two groups of patients were analyzed: Group 50 (n = 30 patients) with a BMI 50-54 kg/m2 and Group 55 (n = 30 patients) with a BMI ≥ 55 kg/m2. 13 different surgeons (9 general and 4 bariatric surgeons) performed the SAGB. All data (demographic and morphologic data, operative data, and follow-up data) were prospectively collected in a computerized data bank. Results: 60 patients (8.8%) out of 682 were super-obese and entered the study. Mean %EWL was 39.2 at 1 year and 60.4 at 4 years, BMI fell from 55.5 to 34.7 at 4 years. The complication rate was 26.7% (16/60). General surgeons 12/60 (20%) had more complications than bariatric surgeons 4/60 (6.7%). In Group 50, mean %EWL was 42.1 at 1 year, 55.9 at 2 years, 61.5 at 3 years and 59.9 at 4 years. BMI fell from 51.8 to 33.2 at 4 years. Postoperative complications occurred in 6/30 patients (20%): pouch dilatation (n=2), band migration (n=2) and band leakage (n=2). In Group 55, mean %EWL was 36.8 at 1 year, 55.3 at 2 years, 55.8 at 3 years, and 59.4 at 4 years. BMI fell from 59.1 to 36.4 at 4 years. Postoperative complications occurred in 10/30 patients (33.3%): pouch dilatation (n=2), band migration (n=3) and band leakage (n=5). There was no mortality. Conclusion: SAGB is an effective procedure for the surgical treatment of super-obesity. Because of the high complication rate, super-obese patients should only be treated by experienced bariatric surgeons.

Laparoscopic Gastric Re-Banding versus Laparoscopic Gastric Bypass as a Rescue Operation for Patients with Pouch dilatation

Background:The authors assessed whether laparoscopic rebanding or laparoscopic Roux-en-Y gastric bypass (LRYGBP) is the best approach for failed gastric banding after pouch dilatation. Methods: Between January 2000 and June 2005, 489 patients underwent laparoscopic gastric banding, and of these, 33 (6.7%) required rescue procedures for pouch dilatation. Each reoperated patient was contacted to obtain information about their postoperative course. Additionally, preoperative weight and BMI, weight loss at 1 year postoperatively, weight at time of pouch dilatation and the time-period between the primary operation and pouch dilatation were analyzed. Results: The most common operation for pouch dilatation was band repositioning or rebanding (16 patients). Band removal without replacement was performed in 7 patients. 8 patients underwent conversion to a LRYGBP. 1 patient underwent laparoscopic gastric sleeve resection and 1 patient received an intragastric balloon. Patients who underwent conversion to LRYGBP are very content and, although weight loss has been nearly the same as after gastric banding, they would prefer the gastric bypass operation to the gastric banding. Conclusion: Conversion to LRYGBP appears to offer significant advantages, and appears to be the rescue therapy of choice after failed laparoscopic gastric banding.

International multicenter study of safety and effectiveness of Swedish Adjustable Gastric Band in 1-, 3-, and 5-year follow-up cohorts

BACKGROUNDnNo long-term, international, multicenter studies of the effectiveness and safety of the SAGB in morbid obesity have been previously published. The objective of this study was to assess the effectiveness and safety of the Swedish Adjustable Gastric Band (SAGB) at 6 bariatric centers in Australia, Europe, and Brazil, with < or =5 years of follow-up; the effect on patient covariates; and changes in co-morbidity.nnnMETHODSnA 2-phase study design was used, involving both retrospective and prospective data. SAGB was implanted by way of the pars flaccida 1, 3, and 5 years previously. The retrospective phase entailed a review of the records. The prospective phase included a subset of eligible patients who agreed to undergo additional clinical assessments. The percentage of excess weight loss (%EWL), patient level predictors, change in co-morbidities, and complications were analyzed.nnnRESULTSnA total of 481 patients in 3 mutually exclusive follow-up cohorts (1 yr, n = 200; 3 yr, n = 184; 5 yr, n = 97) participated in the present study. Of these 481 patients, 339 (1 yr, n = 139; 3 yr, n = 131; 5 yr, n = 69) underwent prospective evaluations. The mean %EWL was 43.5% + or - 21.8%, 57.7% + or - 25.9%, and 49.8% + or - 27.6% and the mean change in body mass index was -7.64, -10.75, and -9.52 in the 1-, 3-, and 5-year cohorts, respectively (P <.001). Gender and age did not predict the %EWL; however, a greater preoperative body mass index was inversely related to the %EWL. Longer postimplantation times were associated with greater improvement in co-morbidities and with greater frequencies of reoperation. Fewer than 15% of the patients in the 5-year cohort had undergone band removal and 10% required band revisions. No fatal or life-threatening complications occurred.nnnCONCLUSIONnSAGB is safe and effective in inducing weight loss and improvement of co-morbidities in morbidly obese patients at international bariatric centers at 1, 3, and 5 years postoperatively.

A-FABP—A Biomarker Associated With the Metabolic Syndrome and/or an Indicator of Weight Change?

Objective: Adipocyte fatty acid‐binding protein (A‐FABP) is a plasma biomarker recently associated with the metabolic syndrome. The aim of these studies was to investigate changes of A‐FABP during profound weight loss induced by laparoscopic adjustable gastric banding (LAGB).

Weight Loss and Quality of Life After Gastric Band Removal or Deflation

BackgroundThe study aim was to retrospectively assess whether patients were able to maintain their weight after gastric band removal or deflation and how they felt about gastric banding.MethodsA total of 41 patients (93% female, mean age 34.1 (SD 10.5) years) were included in this study: patients who had their band removed/deflated without further surgical intervention (group 1, nu2009=u200926) and those who later underwent a second bariatric operation (group 2, nu2009=u200915). We evaluated weight gain after band removal/during the time between band removal and second bariatric operation.ResultsOf our patients, 31 (76%) suffered a complication (18 late pouch dilatations, six band infections, five band migrations, and two band leaks) requiring band removal. Ten patients wanted their band removed (six) or emptied (four). Mean time after band removal, when patients had neither a band nor a second bariatric operation, was 2.84 (SD 2.3) years. Five (12.2%) patients maintained their weight, four of whom experienced a learning effect; all others gained weight. Mean body mass index for both groups after the period without a band was 36.7 (SD 8.0) kg/m2 (vs 29.4 (SD 7.0) at removal), and excess weight loss was 33.2% (SD 39.2; vs 69.8% (SD 32.9) at removal). Of our patients, 73% would not agree to gastric banding again. According to the bariatric analysis and reporting outcome system, long-term outcome of patients following band removal was a “failure” in 66% of patients.ConclusionsLong-term outcome following band removal is unsatisfactory in many patients. Nevertheless, a minority of patients was able to maintain its weight loss.

High Complication Rate after Swedish Adjustable Gastric Banding in Younger Patients ≤25 Years

BackgroundSwedish adjustable gastric banding (SAGB) is an effective treatment for morbid obesity. The main advantage of this procedure is that this operation is minimally invasive to the stomach and totally reversible and adjustable to the patient’s needs. The aim of this observational study is to present our experience with patients ≤25xa0years old.MethodsBetween January 1996 and January 2006, 107 patients (85 women, 22 men) of 785 consecutive patients who underwent SAGB during the study period were aged ≤25xa0years (13.6%). All data (demographic and morphologic data, operative data, and follow-up data) were prospectively collected in a computerized data bank. The postoperative follow-up program was performed most of the time by residents, and 17 different surgeons performed the operation.ResultsThe mean total weight loss was 27xa0kg after 1xa0year, reaching a total of 40xa0kg after 8xa0years. The mean EWL was 65.5% after 8xa0years, and the BMI decreased from 43.3 to 28.2xa0kg/m2. In the 107 patients, there were 50 patients with 72 complications (46.7%) and 57 patients with no complication (53.3%). The most common complications were esophagitis (25.2%), pouch dilation (16.8%), port problems (6.5%), esophageal dilation (5.6%) and band leakage (4.7%). Overall, 31 patients (29%) needed a reoperation. There was no mortality.ConclusionSAGB operation and the follow-up should only be performed by a small team of bariatric surgeons. Because of the high complication and reoperation rate, a gastric-band-specific patient selection will be necessary. On the basis of 8xa0years follow-up, SAGB is an effective bariatric procedure for achieving weight loss.

The Implantable Gastric Stimulator for Obesity

AbstractObjective: To evaluate the efficacy of a gastric stimulation procedure for the treatment of morbid obesity.n Methods: All implantable gastric stimulator systems were implanted in a laparoscopic procedure. We focused on the results of the LOSS (Laparoscopic Obesity Stimulation Survey) study, which was a multicenter European survey of 16 hospitals. To date, 91 patients have undergone implantable gastric stimulator implantation in the LOSS study.n Results: The patient population was comprised of 62 (68%) women and 29 (32%) men. The mean age was 41 years, mean weight was 116kg, and mean body mass index was 41 kg/m2. All surgical procedures were successfully completed. There were no deaths, and no severe peri- or postoperative complications. The mean excess weight loss (EWL) was 20% at 12 months after surgery and about 25% at 2 years after implantation. Baroscreen-selected patients achieved a 31.4% EWL, which was significantly different to the EWL of those patients who were not selected by this screening (15% EWL) [p < 0.01].n Conclusion: Gastric pacing is a promising, minimally invasive, safe, and effective surgical method that results in very little impairment of the patient. Patient selection for gastric stimulation therapy seems to be an important determinant of treatment outcome.

Disappointing mid-term results after laparoscopic gastric banding in young patients

BACKGROUNDnWhen gastric banding was introduced as a bariatric operation about 12 years previously, its early results were promising, with a low complication rate. Only a few long-term studies on this subject have been published. This study was performed to assess our results with laparoscopic gastric banding in young patients after<or=10 years of follow-up.nnnMETHODSnFrom January 1996 to December 2000, a total of 41 patients (83% female, 17% male)<25 years old underwent laparoscopic gastric banding at our institution. The patient data were derived from the electronic patient data system, paper charts, and a telephone interview. Psychosocial changes were analyzed using the Moorehead-Ardelt/Bariatric Analysis and Reporting Outcome System questionnaire.nnnRESULTSnThe mean preoperative body mass index was 44.26+/-6.53 kg/m2, with a mean excess weight of 65.22+/-20.48 kg. The body mass index after 1, 5, and 7 years was 31.50+/-7.38 kg/m2, 31.12+/-7.10 kg/m2, and 32.88+/-5.68 kg/m2, respectively. The mean excess weight loss after 1 year was 60.07%+/-25.33%, and after 5 and 7 years, it was 64.84%+/-27.45% and 57.48%+/-28.07%, respectively. An improvement in obesity-related co-morbidities was observed in nearly all patients. Of our patients, 52% had complications requiring reoperation (27% pouch dilation, 10% band leakage, 5% intragastral band migration, 5% perforation of either the esophagus or the stomach, and 5% port disconnection). According to Bariatric Analysis and Reporting Outcome System, the long-term outcome was regarded as a failure in 40%, fair in 4%, good in 28%, very good in 20%, and excellent in 8% of patients.nnnCONCLUSIONnOur mid-term results were disappointing, with a high complication rate and many dissatisfied patients.

Is a Routine Liquid Contrast Swallow Following Laparoscopic Gastric Banding Mandatory

Background: The authors assess the value of liquid contrast medium swallow as a method to detect postoperative complications after laparoscopic adjustable gastric banding (LAGB) for the treatment of morbid obesity. Methods: From January 1996 to January 2001, 350 morbidly obese patients (295 women, 55 men) underwent a LAGB operation. All data were prospectively collected in a computerized databank. All patients underwent a jopomidol swallow (JS) study in the early postoperative phase to exclude perforation of the esophagus or stomach, which is one of the most serious complications occurring after the LAGB operation. Furthermore, the JS was performed to confirm band position and to exclude early pouch dilatation. Results: Out of the 350 LAGB operations, 6(1.8%) early pouch dilatations and 4(1.2%) stomach perforations occurred. All early pouch dilatations were recognized on postoperative JS and immediately repaired laparoscopically. Of the perforations, one was recognized intraoperatively, and the other three were diagnosed postoperatively, either by contrast media extravasation on the JS (two patients) or by computer tomography. Conclusion: Presently,all patients undergo routine postoperative JS, which exposes them to radiation, causes patient discomfort, and entails additional costs of approximately 100 US