George Fielding

Serum fat-soluble vitamin deficiency and abnormal calcium metabolism after malabsorptive bariatric surgery

Weight loss after biliopancreatic diversion or duodenal switch is due to decreased calorie absorption secondary to fat malabsorption. Fat malabsorption may also cause essential fat-soluble vitamin deficiencies, which may have severe clinical consequences and alter calcium metabolism. Serum vitamins A, D, E, and K, zinc, parathyroid hormone, corrected calcium, and alkaline phosphatase levels were measured in a cohort of patients who had previously undergone biliopancreatic diversion. Two bariatric surgery units were involved in the study: New York University School of Medicine (New York, NY), and the Wesley Medical Center (Brisbane, Australia). A total of 170 patients completed the study. The incidence of vitamin A deficiency was 69%, vitamin K deficiency 68%, and vitamin D deficiency 63% by the fourth year after surgery. The incidence of vitamin E and zinc deficiency did not increase with time after surgery. The incidence of hypocalcemia increased from 15% to 48% over the study period with a corresponding increase in serum parathyroid hormone values in 69% of patients in the fourth postoperative year. There is a progressive increase in the incidence and severity of hypovitaminemia A, D, and K with time after biliopancreatic diversion and duodenal switch. Calcium metabolism is affected with an increasing incidence of secondary hyperparathyrodisim and evidence of increased bone resorption in 3% of patients. Long-term nutritional monitoring is necessary after malabsorptive operations for morbid obesity.

Laparoscopic right hepatectomy:: Surgical technique

The objective of this study was to demonstrate the safety of laparoscopic right hepatectomy for benign or malignant disease. Many reports document the success of minor or segmental liver resections performed laparoscopically. Major hepatic resection has rarely been reported. This report documents our experience with 12 laparoscopic right hepatectomies. Ten patients had suspected malignancy, but all had lesions well clear of the midplane of the liver. The surgery followed three distinct phases: (1) Portal dissection during which diathermy and harmonic shears are used, clips are applied to the right hepatic duct and right hepatic artery, and a vascular stapler is used to divide the right portal vein; (2) dissection of the vena cava, which is usually done by tunneling below the liver using harmonic shears, clips, and a linear stapler to divide the right hepatic vein; and (3) parenchymal division during which harmonic shears and multiple firings of linear staplers are used to divide the liver substance. In five patients the procedure was completed totally laparoscopically, five patients had a laparoscopic-assisted procedure, and two patients had to be converted to formal open hepatectomy. Four patients required blood transfusion. There were no deaths and two cases of major morbidity—bile leakage in one and wound dehiscence in one. The average hospital stay was 8 days, but for those whose operations were completed totally laparoscopically, 4 days was the average. Two of the nine patients with documented cancer have since died—one with widespread intrahepatic hepatocellular carcinoma and another with widespread metastatic melanoma after resection of a colorectal metastasis. Seven patients with colorectal cancer are alive and disease free with follow-up of 6 to 24 months. Laparoscopic right hepatectomy is feasible in selected patients. It is technically demanding but can be safely accomplished by surgeons who have experience in advanced laparoscopic procedures and open hepatic surgery.

Postoperative ERCP Versus Laparoscopic Choledochotomy for Clearance of Selected Bile Duct Calculi: A Randomized Trial

Objective:Prospectively evaluate whether for patients having laparoscopic cholecystectomy with failed trans-cystic duct clearance of bile duct (BD) stones they should have laparoscopic choledochotomy or postoperative endoscopic retrograde cholangiography (ERCP). Summary Background Data:Clinical management of BD stones found at laparoscopic cholecystectomy in the last decade has focused on pre-cholecystectomy detection with ERCP clearance in those with suspected stones. This clinical algorithm successfully clears the stones in most patients, but no stones are found in 20% to 60% of patients and rare unpredictably severe ERCP morbidity can result in this group. Our initial experience of 300 consecutive patients with fluoroscopic cholangiography and intraoperative clearance demonstrated that, for the pattern of stone disease we see, 66% of patients’ BD stones can be cleared via the cystic duct with dramatic reduction in morbidity compared to the 33% requiring choledochotomy or ERCP. Given the limitations of the preoperative approach to BD stone clearance, this trial was designed to explore the limitations, for patients failing laparoscopic trans-cystic clearance, of laparoscopic choledochotomy or postoperative ERCP. Methods:Across 7 metropolitan hospitals after failed trans-cystic duct clearance, patients were intraoperatively randomized to have either laparoscopic choledochotomy or postoperative ERCP. Exclusion criteria were: ERCP prior to referral for cholecystectomy, severe cholangitis or pancreatitis requiring immediate ERCP drainage, common BD diameter of less than 7 mm diameter, or if bilio-enteric drainage was required in addition to stone clearance. Drain decompression of the cleared BD was used in the presence of cholangitis, an edematous ampulla due to instrumentation or stone impaction and technical difficulties from local inflammation and fibrosis. The ERCP occurred prior to discharge from hospital. Mechanical and extracorporeal shockwave lithotripsy was available. Sphincter balloon dilation as an alternative to sphincterotomy to allow stone extraction was not used. Major endpoints for the trial were operative time, morbidity, retained stone rate, reoperation rate, and hospital stay. Results:From June 1998 to February 2003, 372 patients with BD stones had successful trans-cystic duct clearance of stones in 286, leaving 86 patients randomized into the trial. Total operative time was 10.9 minutes longer in the choledochotomy group (158.8 minutes), with slightly shorter hospital stay 6.4 days versus 7.7 days. Bile leak occurred in 14.6% of those having choledochotomy with similar rates of pancreatitis (7.3% versus 8.8%), retained stones (2.4% versus 4.4%), reoperation (7.3% versus 6.6%), and overall morbidity (17% versus 13%). Conclusions:These data suggest that the majority of secondary BD stones can be diagnosed at the time of cholecystectomy and cleared trans-cystically, with those failing having either choledochotomy or postoperative ERCP. However, because of the small trial size, a significant chance exists that small differences in outcome may exist. We would avoid choledochotomy in ducts less than 7 mm measured at the time of operative cholangiogram and severely inflamed friable tissues leading to a difficult dissection. We would advocate choledochotomy as a good choice for patients after Billroth 11 gastrectomy, failed ERCP access, or where long delays would occur for patient transfer to other locations for the ERCP.

A clinical and nutritional comparison of biliopancreatic diversion with and without duodenal switch

Objective:To compare biliopancreatic diversion (BPD) without duodenal switch (DS) and with duodenal switch (BPDDS). Background:A reduction of 70% of excess body weight can be achieved after BPD, but there is a risk of malnutrition and diarrhea. This risk may be reduced by pyloric preservation with BPDDS. Methods:BPD was performed until 1999, when BPDDS was introduced, both with a common channel of 50 cm. At their latest clinic visit, patients filled in a questionnaire regarding weight loss, dietary history, gastrointestinal symptoms, obesity-related comorbidity, and medication including dietary supplements and underwent a serum nutritional screen. Results:BPD was performed in 73 patients and BPDDS in 61 patients, with a median preoperative body mass index (BMI) of 44.8 kg/m2 and a median follow-up of 28 months. There were no significant differences between BPD and BPDDS with regards to age, sex, BMI, or morbidity. Median excess weight loss and BMI at 12, 24, and 36 months was 64.1, 71.0, and 72.1% and 33.1, 31.5, and 31.5 kg/m2, respectively; there were no significant differences between BPD and BPDDS. There were no significant differences between BPD and BPDDS with regards to meal size, fat score, nausea, vomiting, diarrhea, or nutritional parameters. However, 18% of patients were hypoalbuminemic, 32% anemic, 25% hypocalcemic, and almost half had low vitamin A, D, and K levels, despite more than 80% taking vitamin supplementation. Conclusion:DS does not improve weight loss or lessen the gastrointestinal or nutritional side effects of BPD.

Laparoscopic gastric banding for morbid obesity. Surgical outcome in 335 cases.

AbstractBackground: Morbid obesity occurs in 2–5% of the population of Europe, Australia, and the United States and is becoming more common. Open surgical techniques, such as vertical banded gastroplasty and other divisional procedures in the stomach, have led to long-term weight reduction as well as an amelioration of the attendant medical problems in approximately two-thirds of patients. Materials and methods: A total of 335 patients with a median age of 41 years underwent gastric banding. We emphasized the need for long-term maintenance and follow-up. The indications for surgery comprised a body mass index >35, a stated desire to undergo the procedure, and a full understanding of all possible complications. Results: All patients have needed band adjustments of 1–4 ml over the course of their follow-up. No patient had increased his or her weight during the follow-up, and only three patients have not enjoyed sustained weight loss. Conclusions: Laparoscopic gastric banding has much to recommend it. Certainly in the short term, its results in terms of effectiveness of weight loss are at least as good as those of any open procedure. Longer follow-up will show whether this weight loss is maintainable. The procedure is technically demanding, and the major prerequisite of satisfactory performance of this surgery is laparoscopic experience.

Calcium and Vitamin D Depletion and Elevated Parathyroid Hormone following Biliopancreatic Diversion

Background: Biliopancreatic diversion (BPD) is associated with a 70% excess weight loss (EWL) at 10 years, but there are concerns regarding long-term nutritional sequelae. Metabolic bone disease has been documented following Roux-en-Y gastric bypass. Methods: Patients who underwent a BPD from 1998 to 2001 were studied. A questionnaire was designed to review BPD patients and collect information on weight loss, frequency of gastrointestinal disturbances and compliance with multivitamin recommendations. The review included a blood test for vitamin D, parathyroid hormone (PTH), alkaline phosphatase (ALP) and calcium. Results: Of the 82 patients who underwent BPD during this period, the median %EWL at 36 months was 73.0%. 75.6% suffered diarrhea. At median follow-up of 32 months (18-50), 25.9% of patients were hypocalcemic, 50% had low vitamin D, 23.8% had elevated ALP, and 63.1% had elevated PTH, despite 82.9% taking multivitamins. Conclusion: BPD results in significant weight loss. However, 1 in 4 patients are hypocalcemic, and 1 in 2 have a low vitamin D, despite multivitamin supplementation. BPD patients require routine calcium and vitamin D supplementation for life. Long-term sequelae from these abnormal serum levels are not known.

A step-by-step guide to placement of the LAP-BAND adjustable gastric banding system

The early promise of laparoscopic adjustable gastric banding was tempered by reports of high rates of gastric herniation or prolapse. These complications are a function of the operative technique used early on. At the time, in the early 1990s, the LAP-BAND device (INAMED Health, Santa Barbara, CA) was placed lower on the stomach, near the first short gastric vessel. The required perigastric dissection was difficult and variable in its extent, depending on the width of the stomach and where the surgeon began the dissection. To combat these problems, a new surgical method for placement of the band has evolved. Called the pars flaccida technique, it emphasizes minimal dissection and placement of the LAP-BAND out of the lesser sac. This leads to a higher position of the band, away from the body of the stomach. The technique serves to make band placement simple, safe, reproducible, and easily teachable, as well as to decrease the rate of gastric herniation or prolapse. Keeping the band out of the lesser sac, away from the peristalsing stomach, minimizing dissection of the attachments to the stomach, paying strict attention to gastric-to-gastric suturing, and leaving all fluid out of the band until at least 6 weeks after surgery appear to be the most important factors in reducing the incidence of this complication.

Towards T-tube free laparoscopic bile duct exploration: a methodologic evolution during 300 consecutive procedures.

OBJECTIVE To establish a simple, reproducible, and safe technique of laparoscopic common bile duct exploration (CBDE) with high clearance rates and low morbidity and mortality rates. SUMMARY BACKGROUND DATA For most general surgeons, laparoscopic CBDE appears an unduly complex and demanding procedure. Since the introduction of laparoscopic cholecystectomy, many surgeons use endoscopic cholangiography (ERC) and endoscopic sphincterotomy as their only option in treating bile duct stones. ERC is more specific if used after surgery, but it carries an appreciable morbidity rate and has the disadvantage of requiring a second procedure to deal with bile duct stones. To this end, various methods of laparoscopic CBDE have been developed. METHODS Between August 1991 and February 1997, 300 consecutive unselected patients underwent laparoscopic CBDE. RESULTS Of 300 laparoscopic CBDE procedures, 173 (58%) were managed using a transcystic approach and 127 (42%) with choledochotomy. Successful laparoscopic stone clearance was achieved in 271 (90%). Of the 29 (10%) patients not cleared laparoscopically, 10 had an elective postsurgical ERC, 12 were converted to an open procedure early in the series, and 7 had unexpected retained stones. There was one death (mortality rate 0.3%) and major morbidity occurred in 22 patients (7%). The last 100 procedures were performed from July 1995 to February 1997, and stone clearance was unsuccessful in only two patients. CONCLUSIONS Laparoscopic transcystic basket extraction of common duct stones under fluoroscopic guidance is a relatively quick, successful, and safe technique. Choledochotomy, when required, is associated with a higher morbidity rate, particularly with T-tube insertion, and the authors advocate primary bile duct closure with or without insertion of a biliary stent as a more satisfactory technique for both surgeon and patient. Most patients with gallbladder and common duct calculi should expect a curative one-stage laparoscopic procedure without the need for external biliary drainage or ERC.

Laparoscopic Gastric Banding in Morbidly Obese Adolescents

Background: 4% of adolescents in the U.S.A. are obese, 80% of whom will become obese adults. Obesity in adolescence is associated with increased mortality and morbidity in adulthood. Is laparoscopic adjustable silicone gastric banding a safe and effective method of weight loss in morbidly obese adolescents? Methods: Since 1996, data has been prospectively collected on all patients undergoing laparoscopic adjustable gastric banding (LAGB) by a single surgeon. Patients are reviewed at 6 and 12 weeks following surgery,then at 3 monthly intervals.Weight loss is measured in absolute terms, reduction in body mass index (BMI) and as percentage of excess weight loss. Results: 17 patients with a median age of 17 (12 to 19) years underwent LAGB. Median follow-up was 25 (12 to 46) months. 2 complications occurred, 1 slipped band and 1 leaking port. BMI fell from a preoperative median of 44.7 to 30.2 kg/m2 at 24 months following surgery, corresponding to a median loss of 35.6 kg or 59.3% of excess weight. 13 of 17 patients (76.5%) lost at least 50% of their excess weight, and 9 of 11 patients (81.8%) had a BMI <35 kg/m2 at 24 months following surgery. Conclusion: LAGB is a safe and effective method of weight loss in morbidly obese adolescents, at least in the medium term. Its role in preventing obesity and obesity-related disease in adulthood remains to be determined as part of our long-term study.

An update on 73 US obese pediatric patients treated with laparoscopic adjustable gastric banding: comorbidity resolution and compliance data

BACKGROUND Adolescent obesity continues to present one of the most difficult and important challenges for both the pediatric and adult medical communities. Evidence is mounting that bariatric surgery is the only reliable method for substantial and sustainable weight loss; however, the debate continues with regard to the optimal surgical procedure for both adolescents and adults. Although most US adult bariatric surgeons prefer the gastric bypass, our institution has demonstrated equivalent weight loss with significantly less morbidity using laparoscopic adjustable gastric banding (LAGB) in both adults and adolescents. This analysis is an update of our results in our first 73 patients, including resolution of comorbid conditions and compliance data. METHODS All adolescents aged 13 to 17 years who have undergone LAGB at our institution have been entered into our prospectively collected database since September 2001 and were reviewed. Data collected preoperatively included age, sex, race, body mass index (BMI), and presence of comorbid conditions. Postoperatively recorded data included length of stay, operative morbidity, need for reoperation, percentage of excess weight loss (%EWL), and BMI at 3-month intervals; status of any comorbid conditions, and number of postoperative visits and band adjustments. RESULTS Seventy-three adolescents aged 13 to 17 years (mean, 15.8 +/- 1.2 years) have undergone LAGB at our institution since September, 2001. Of these, 54 were female and 19 were male. The mean preoperative weight was 298 lb, with a BMI of 48 kg/m(2). The %EWL at 6 months, 1 year, and 2 years postoperatively was 35% +/- 16%, 57% +/- 23%, and 61% +/- 27%, respectively. One patient experienced a gastric perforation after a reoperation for band replacement because of a slip. One additional patient requested band removal because of restriction intolerance after a slip. A total of 6 patients developed band slippage, and 3 patients developed symptomatic hiatal hernias. Nutritional complications included asymptomatic iron deficiency in 13 patients, asymptomatic vitamin D deficiency in 4 patients, and mild subjective hair loss in 14 patients. In 21 patients who entered our Food and Drug Administration-approved study and had reached 1-year follow-up, there were 51 identified comorbid conditions. Of these, 35 (68.5%) were completely resolved, 9 (17.5%) were improved, 5 (10%) were unchanged, and 2 (4%) were aggravated after 1 year. Of 50 initial patients who underwent surgery more than 1 year ago, 2 patients lived a large distance from our institution, where band maintenance is being performed locally, and thus, the patients were excluded from the analysis. Two patients were lost to follow-up in the first year, and 3 patients were lost to follow-up in the second year, for an overall compliance rate of at least 89.5%. The mean number of office visits was 10 +/- 3 in the first year, and the mean number of adjustments was 6 +/- 2. CONCLUSIONS Laparoscopic adjustable gastric banding continues to represent an attractive treatment strategy for morbidly obese pediatric patients with a %EWL of more than 55% at both 1- and 2-year follow-up, with minimal morbidity compared with the gastric bypass. Furthermore, the weight loss associated with LAGB provides excellent resolution or improvement of comorbid conditions. Although there is a necessary commitment by the patient that involves frequent office visits and band adjustments, adolescents are entirely capable of this commitment, and noncompliance should not be a reason to dissuade adolescents from having LAGB. It remains, in our opinion, the optimal surgical option for pediatric patients with morbid obesity.