Heekoung Youn

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.

Laparoscopic adjustable gastric banding for morbidly obese adolescents affects android fat loss, resolution of comorbidities, and improved metabolic status.

BACKGROUND The distribution of weight loss and its impact on metabolic health has not been documented for laparoscopic adjustable gastric banding (LAGB) in the adolescent population. We hypothesized that LAGB in obese adolescents would result in loss of android fat mass, resolution of comorbidities, and improvement in metabolic status. STUDY DESIGN Adolescents ages 14 to 17 who met criteria for bariatric surgery were enrolled in our FDA-approved LAGB trial. Demographic data, body mass index, body composition and bone density, laboratory evaluations, and comorbid conditions were assessed pre- and postoperatively. RESULTS Forty-five patients had complete 1-year followup and 41 patients had complete 2-year followup. Mean preoperative weight was 299 + or - 57 lb and body mass index was 48 + or - 6.4 kg/m(2). The percent excess weight losses at 6 months, 1 year, and 2 years were 31 + or - 16, 46 + or - 21, and 47 + or - 22, respectively. At 1-year followup, patients after LAGB had a significant decrease in their total and android fat mass. In addition, 47 of 85 identified comorbidities (55%) were completely resolved and 25 (29%) were improved in comparison with baseline. Improvements in alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase, hemoglobin A1c, fasting insulin, triglycerides, and high density lipoprotein, were also seen. CONCLUSIONS The percent excess weight loss after LAGB in morbidly obese adolescents is approximately 45% at 1- and 2-year followup, with the majority of weight loss consisting of android fat mass. Resolution or improvement of comorbidities is seen, and improved metabolic status, as demonstrated by liver function tests, lipid levels, and measures of glucose homeostasis, may be expected. These data support LAGB as an appropriate surgical option for morbidly obese adolescents.

Five-year outcomes of patients with type 2 diabetes who underwent laparoscopic adjustable gastric banding

BACKGROUND Evidence of the positive effects of gastric banding on patients with diabetes has continued to increase. The long-term follow-up of such patients, however, has been limited. The purpose of the present study was to provide the long-term outcomes of patients with diabetes undergoing laparoscopic adjustable gastric banding at our institution. METHODS From January 2002 through June 2004, 102 patients with type 2 diabetes mellitus underwent laparoscopic adjustable gastric banding. The study parameters included preoperative age, gender, race, body mass index, duration of diabetes before surgery, fasting glucose level, hemoglobin A1c (HbA1c), and medications used. Preoperative data from all patients were collected prospectively and entered into an institutional review board-approved database. Beginning in 2008, efforts were made to collect the 5-year follow-up data. RESULTS Of the 102 patients, 7 were excluded because they had not reached the 5-year follow-up point (2 patients had had the band removed early and 5 patients had died; 2 of cancer and 3 of unknown causes), leaving 95 patients for the present study. The mean preoperative age was 49.3 years (range 21.3-68.4). The mean preoperative body mass index was 46.3 kg/m(2) (range 35.1-71.9) and had decreased to 35.0 kg/m(2) (range 21.1-53.7) by 5 years of follow-up, yielding a mean percentage of excess weight loss of 48.3%. The mean duration of the diabetes diagnosis before surgery was 6.5 years. Of 94 patients, 83 (88.3%) were taking medications preoperatively, with 14.9% overall taking insulin. At 5 years postoperatively, 33 (46.5%) of 71 patients were taking medications, with 8.5% taking insulin. The mean fasting preoperative glucose level was 146.0 mg/dL. The glucose level had decreased to 118.5 mg/dL at 5 years postoperatively (P = .004). The mean HbA1c level was 7.53 preoperatively in 72 patients and was 6.58 at 5 years postoperatively in 64 patients (P <.001). Overall, diabetes had resolved (no medication requirement, with HbA1c <6 and/or glucose <100 mg/dL) in 23 (39.7%) of 58 patients and had improved (use of fewer medications and/or fasting glucose levels of 100-125 mg/dL) in 41 (71.9%) of 57 patients. The combined improvement/remission rate was 80% (64 of 80 patients). CONCLUSION Our data have demonstrated that laparoscopic adjustable gastric banding results in a substantial sustained positive effect on diabetes in morbidly obese patients, with a significant reduction in HbA1c and an 80% overall rate of improvement/remission.

Midterm results for gastric banding as salvage procedure for patients with weight loss failure after Roux-en-Y gastric bypass

BACKGROUND Studies reporting the revisionary options for weight loss failure after Roux-en-Y gastric bypass (RYGB) have been complex, underpowered, and lacking long-term data. We have previously shown that short-term (12-month) weight loss is achievable with laparoscopic adjustable gastric banding (LAGB) for failed RYGB. To report the midterm outcomes of LAGB after RYGB failure. METHODS A retrospective review of prospectively collected data before and after RYGB, when available, and before and after LAGB was performed at the New York Langone University Hospital (New York, NY). The data collected included weight, height, body mass index (BMI), gender, race, age, operative time, length of stay, postoperative complications, and the percentage of excess weight loss. RESULTS A total of 43 patients (9 men and 34 women) underwent LAGB after weight loss failure with RYGB. Of the 43 patients, 27 patients had undergone RYGB at other institutions, and preoperative RYGB data were available for 23 total patients. The average interval to LAGB was 6.6 years. The mean BMI before RYGB was 50.4 kg/m(2) and before LAGB was 43.3 kg/m(2) (%EWL was 17% after RYGB). At follow-up after LAGB, the average BMI was 35.2 kg/m(2), with a %EWL of 38% (calculated from LAGB only) at 26 months (range 6-66). At the 1- and 2-year follow-up visit, the BMI had decreased by 8.7 kg/m(2). The reoperation rate for complications related to LAGB was 10% and included 2 band erosions, 1 band slip, and 1 port flip. CONCLUSION The results of our study have shown that LAGB had good midterm data as a revisionary procedure for weight loss failure after RYGB.

Improvement in nonalcoholic fatty liver disease and metabolic syndrome in adolescents undergoing bariatric surgery.

BACKGROUND Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in children. It is linked to obesity and the metabolic syndrome (MS), predisposing to future cirrhosis. The objective of this study was to demonstrate the effects that weight loss achieved with laparoscopic adjustable gastric band (LAGB) has on the metabolic parameters and NAFLD scores of obese adolescents with evidence of fatty liver disease. METHODS Adolescents undergoing LAGB were evaluated for NAFLD with evidence of fatty liver on preoperative sonogram, serum biochemistry, or both between 2005 and 2011. Primary endpoint was change in NAFLD scores after LAGB and secondary endpoint change in MS criteria. RESULTS Fifty-six out of 155 adolescents had evidence of fatty liver disease at presentation. The group consisted of 17 (30%) male and 39 (70%) females, mean age 16.1 years (range 14-17.8 yr). Preoperative body mass index (BMI) was 48.8 kg/m(2) (±7) dropping to 37.9 kg/m(2) (±8.3) at 12 months and 36.8 kg/m(2) (±8.2) at 24 months. Fifteen (27%) patients met the criteria for MS. When comparing 1-year postsurgery to presurgery, the NAFLD score decreased by an average of .68 (SD = 1.03, P<.01). The 2-year NAFLD score decreased by a mean of .38 (SD = .99, P = .01). The reoperation rate for band/port related complications was 10.7% at 2 years with no mortality. MS rates improved from 27% to 2% at 2 years (P< .01). CONCLUSIONS LAGB is a safe and effective operation for obese adolescents with NAFLD. There was significant improvement in NAFLD scores and resolution of MS.

Safety and efficacy of laparoscopic adjustable gastric banding in patients aged seventy and older

BACKGROUND Life expectancy is increasing, with more elderly people categorized as obese. The objective of this study was to assess the effects of laparoscopic adjustable gastric banding (LAGB) on patients aged ≥ 70 years. METHODS This was a retrospective analysis of patients aged ≥ 70 years who underwent LAGB at our university hospital between 2003 and 2011. The data included age, weight, body mass index (BMI), and percentage excess weight loss (%EWL) obtained before and after gastric banding. Operative data, length of stay, postoperative complications, and resolution of co-morbid conditions were also analyzed. RESULTS Fifty-five patients aged ≥ 70 years (mean 73 years) underwent gastric banding between 2003 and 2012. Mean preoperative weight and BMI were 123 kilograms and 45 kg/m(2), respectively. On average, each patient had 4 co-morbidities preoperatively, with hypertension (n = 49; 86%), dyslipidemia (n = 40; 70%), and sleep apnea (n = 31; 54%) being the most common. Mean operating room (OR) time was 49 minutes, with all patients discharged within 24 hours. There was 1 death at 4 years from myocardial infarction, no intensive care unit admissions, and no 30-day readmissions. Mean %EWL at 1, 2, 3, 4, and 5 years was 36 (± 12.7), 40 (± 16.4), 42 (± 19.2), 41 (± 17.1), 50 (± 14.9), and 48 (± 22.6), respectively. Follow-up rates ranged from 55/55 (100%) at 6 months to 7/9 (78%) of eligible patients at 5 years and 2/2 (100%) at 8 years. Complications included 1 band slip at year 5, 1 band removed for intolerance, and 1 port site hernia. The resolution of hypertension, dyslipidemia, sleep apnea, lower back pain, and non-insulin-dependent diabetes was 27%, 28%, 35%, 31%, and 35%, respectively. CONCLUSIONS LAGB as a primary treatment for obesity in carefully selected patients aged ≥ 70 can be well tolerated and effective with moderate resolution of co-morbid conditions and few complications.

Surgical management and outcomes of patients with marginal ulcer after Roux-en-Y gastric bypass

BACKGROUND Marginal ulcers (MUs) are potentially complex complications after Roux-en-Y gastric bypass. Although most resolve with medical management, some require surgical intervention. Many surgical options exist, but there is no standardized approach, and few reports of outcomes have been documented in the literature. The objective of this study was to determine the outcomes of surgical management of marginal ulcers. METHODS Data from all patients who underwent surgical intervention between 2004 and 2012 for treatment of MU after previous Roux-en-Y gastric bypass were reviewed. RESULTS Twelve patients with MUs underwent reoperation. Nine patients had associated gastrogastric fistulae (75%). The median time to reoperation was 43 months. Ten patients underwent subtotal gastrectomy, of which 9 had a revision of the gastrojejunal anastomosis and 1 did not. One underwent total gastrectomy with esophagojejunal anastomosis for ulcer after previous revisional partial gastrectomy, and 1 patient underwent video-assisted thoracoscopic truncal vagotomy for persistent ulcer-related bleeding in the early postoperative period. Three patients (25%) experienced postoperative complications associated with revisional surgery requiring reoperation. At median follow-up time of 35 months, 7 patients (58%) had chronic abdominal pain, and 4 patients (33%) had intermittent diarrhea. Three patients (25%) were lost to recent follow-up. None had recurrence of MU. CONCLUSION Patients can undergo one of several available surgical interventions, including laparoscopic subtotal gastrectomy with gastrojejunostomy revision. Though this appears to offer definitive treatment of MU, its benefits must be weighed against the increased risk of significant postoperative complications and chronic symptoms related to revisional surgery.

Effects of laparoscopic adjustable gastric banding on sleep and metabolism: a 12-month follow-up study

Background Obstructive sleep apnea is commonly associated with metabolic changes and obesity, and changes in body weight by either medical or surgical approaches have been considered to affect the severity of sleep apnea and appetite-controlling hormones. This prospective study evaluated the effect of weight loss induced by laparoscopic adjustable gastric banding (LAGB) surgery on respiratory disturbance during sleep, oxygen saturation levels, sleep architecture, and leptin and ghrelin levels. Methods Participants were patients at a university-based medical center surgical weight loss program. All participants with a body mass index > 30 kg/m2 undergoing LAGB surgery for weight reduction were offered the opportunity to participate in the study. Procedures included overnight polysomnography followed by fasting hormone levels at baseline and 12 months postoperatively. Results Thirty subjects (10 men, 20 women) of mean age 44.0 ± 12.5 years were recruited. At 12 months postoperatively, mean excess weight loss was 44.4% ± 14%. The apnea-hypopnea index decreased from 34.2 ± 35 to 19.0 ± 21.7 events per hour (P < 0.0001), while leptin levels decreased from 24.5 ± 17.42 pg/mL to 11.6 ± 10.6 pg/mL (P = 0.02). Ghrelin levels did not change substantially. Nadir oxygen saturation levels increased from 81% to 84% at 12 months (P = 0.03). Mean oxygen saturation improved and was positively correlated with ghrelin levels at both time points (r = 0.39, P = 0.07, and r = 0.60, P = 0.01). Conclusion LAGB surgery was associated with 44.4% excess weight loss at 12 months, accompanied by a 33.7% improvement in apnea-hypopnea index as well as a reduction in leptin levels by 31.7% in this group. An association between ghrelin and mean oxygen saturation was seen and deserves further investigation.

Laparoscopic gastric banding resolves the metabolic syndrome and improves lipid profile over five years in obese patients with body mass index 30–40 kg/m2

BACKGROUND Obesity, metabolic syndrome (MS) and dyslipidemia are independent risk factors for cardiovascular disease. Bariatric surgery is increasingly recognized as an effective intervention for improving each of these risk factors. There are sparse data on the long-term durability of metabolic changes associated with bariatric surgery, in particular with laparoscopic gastric banding (LGB). Our objective was to evaluate the durability of metabolic changes associated with LGB in nonmorbid obesity. METHODS Fifty obese patients (BMI 30-40) with ≥1 obesity-related comorbidity were prospectively followed for five years. At follow-up, subjects underwent fasting blood measures, including lipid NMR spectroscopy and standard lipid profile. RESULTS Forty-seven patients (45 female, mean age 43.8 years) completed four years follow-up (46 completed five years). Baseline BMI was 35.1 ± 2.6. Subjects exhibited mean weight loss of 22.3 ± 7.9 kg (22.9 ± 7.4%) at year one and maintained this (19.8 ± 10.2%) over five years. At baseline, 43% (20/47) of subjects met criteria for MS. This was reduced to 15% (7/47) at year one and remained reduced over five years (13%, 6/46) (p < 0.001). There were reductions in triglycerides (p < 0.001) and increases in HDL cholesterol (HDL-C, p < 0.001) and HDL particle concentration (p = 0.02), with a trend toward increased HDL particle size (p = 0.06) at year five. Changes in triglycerides and HDL-C were more prominent in patients with MS at baseline, but unassociated with weight loss or waist circumference. Changes in HDL particle size and concentration were not associated with MS status, weight loss, waist circumference, or statin use. CONCLUSIONS LGB produces significant weight loss, resolution of MS and changes in lipid profile suggestive of beneficial HDL remodeling. These changes persist five years following LGB.

Predictors of the effect of bariatric surgery on knee osteoarthritis pain

INTRODUCTION Bariatric surgery reduces obesity and knee osteoarthritis (OA) pain, but some patients improve more than others. We aimed to identify characteristics that predict this knee pain improvement. METHODS We reviewed NYU Langone Health bariatrics records (2002-2015) and called eligible patients reporting pre-operative knee pain. Patients were asked to rate their pain on a 10-point scale at three time points: before surgery, one year post-surgery, and time of survey administration. Subjects were asked about pre-operative knee injuries and surgeries, presence of OA in other joints, and OA family history. Data were analyzed using paired t-tests and ANOVA. RESULTS Of 125 eligible patients reporting knee pain, we analyzed the 120 patients who had laparoscopic gastric band (LAGB) surgery. The cohort was 78.3% female, with an average age at surgery of 49.7 ± 10.2 years. There was no correlation between pre-operative body mass index (BMI) and knee pain reduction at one year post-LAGB, but the subgroup with the most BMI improvement reported the most knee improvement (p = 0.043). We found significantly better pain reduction after one year in younger patients (p = 0.009). Those with prior knee injuries improved less than those who were injury-free (p = 0.044), but a history of prior knee surgery was not similarly significant. Patients with multifocal OA improved less (p = 0.001). CONCLUSION Younger knee OA patients and those without prior knee injury or other OA involvement, experience more knee pain relief from LAGB weight loss surgery. LAGB may be a viable treatment option for knee OA pain, irrespective of the degree of obesity.