Karin Dolezalova

Adjustable gastric banding outcomes with and without gastrogastric imbrication sutures: a randomized controlled trial

BACKGROUND The intended purpose of gastrogastric imbrication sutures in laparoscopic adjustable gastric banding is to reduce band-related complications; however, evidence demonstrating imbrication suture utility has been lacking. A 3-year randomized controlled trial on the safety and efficacy of laparoscopic adjustable gastric banding with and without imbrication sutures was undertaken. We performed a prospective investigation of the outcomes using the Swedish adjustable gastric band (SAGB) with and without imbrication sutures. METHODS From January to September 2006, 100 patients undergoing SAGB placement were randomized to group 1 (n = 50, ≥ 2 imbrication sutures) or group 2 (n = 50, no imbrication sutures). The SAGB was implanted in both groups using a standardized pars flaccida technique. The mean operative time, hospitalization time, percentage of excess weight loss, body mass index, band fill volume, and complications were recorded. The Fisher exact test for categorical data, the independent samples t test for continuous data, and the paired t test to assess the body mass index reduction were performed. All tests were 2-tailed, and statistical significance was set at P <.05. RESULTS The mean operative time was 75 ± 7 minutes (range 50-92) and 48 ± 4 minutes (range 32-75) for groups 1 and 2, respectively (P <.001). The mean hospitalization time was 26 ± 12 hours (range 20-96) and 23 ± 9 hours (range 20-48) for groups 1 and 2, respectively (P <.17). The 3-year percentage of excess weight loss was 55.7% ± 3.4% and 58.1% ± 4.1% for groups 1 and 2, respectively (95% confidence interval -4.0% to -.8%, P <.01). The body mass index at 3 years was 34.0 ± 5.8 kg/m(2) and 30.3 ± 6.4 kg/m(2) (range 1.2-6.2) for groups 1 and 2, respectively (P <.01). The fill volume at 3 years was 3.6 ± 1.2 mL (range 1.0-5.5) and 4.5 ± 0.5 mL (range .0-5.0) for groups 1 and 2, respectively (P <.01). Finally, slippage occurred in 1 patient (2.2%) and 1 patient (2.0%) and migration in 1 patient (2.2%) and 1 patient (2.0%) in groups 1 and 2, respectively (P = NS). No patient died in either group. CONCLUSION The results of our randomized controlled trial have demonstrated that SAGB combined with a conservative approach to band adjustments and limited retrogastric dissection is effective and safe with and without imbrication sutures. Not using imbrication sutures results in significant benefits in operative speed with comparable clinical weight loss and intermediate term safety. These randomized controlled trial data suggest that imbrication sutures are not indispensable to laparoscopic adjustable gastric banding and their use can be left to the surgeons discretion.

Validity of the Czech, German, Italian, and Spanish version of the Moorehead-Ardelt II questionnaire in patients with morbid obesity.

Background: The Moorehead-Ardelt II (MA-II) questionnaire is the most frequently applied instrument to assess quality of life (QoL )in bariatric surgery patients. Our aim was to validate the Czech, German, Italian, and Spanish version of the MA-II. Methods: A total of 893 patients were enroled in a prospective cross-sectional European study. Two thirds of the patients (n = 591) were postsurgical cases. In addition to demographic and clinical data, QoL data was collected using the MA-II questionnaire, the EuroQoL-5D (EQ-5D),and the Short Form 36 Health Survery (SF-36). Statistical parameters for contingency (Cronbach’s alpha),construct and criterion validity (Pearson’s r),and responsiveness (standardised effect sizes) were calculated for each language version. Results: In the different languages, Cronbach’s alpha ranged from 0.817 to 0.885 for the MA-II. These values were higher than those obtained for the SF-36 (0.418–0.607). The MA-II was well correlated to the EQ-5D (r = 0.662) and to 3 of the 8healthdomains of the SF-36 (0.615, 0.548, and 0.569 for physical functioning, physical role, and general health, respectively). As expected, there was a negative correlation between the MA-II and the BMI (r = –0.404 for all patients), but no significant correlation with age was found. When comparing both the heaviest and the lightest third of the patients, mean responsiveness was higher for the MA-II (–1.138) than for the domains of the SF-36 (range –0.111 to –1.070) and the EQ-5D (–0.874). Conclusion: The Czech, German, Italian, and Spanish version of the MA-II questionnaire are valid instruments and should be preferred to generic questionnaires as they provide better responsiveness.

A novel approach to glycemic control in type 2 diabetes mellitus, partial jejunal diversion: pre-clinical to clinical pathway

Objective To explore partial jejunal diversion (PJD) via a side-to-side jejuno-jejunostomy for improved glycemic control in type 2 diabetes mellitus (T2DM). PJD is an anatomy-sparing, technically simple surgery in comparison to the predominate metabolic procedures, Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). Positive results in a rodent model prompted a human proof-of-concept study. Research design and methods Pre-clinically, 71 rats were studied in a model of metabolic dysfunction induced by a high-fat diet; 33 animals undergoing one of two lengths of PJD were compared with 18 undergoing sham, 10 RYGB and 10 jejuno-ileal bypass. Clinically, 15 adult subjects with treated but inadequately controlled T2DM (hemoglobin A1c (HbA1c) of 8.0%–11.0%), body mass index of 27.0–40.0 kg/m2, and C peptide ≥3 ng/mL were studied. Follow-up was at 2 weeks, and 3, 6, 9, and 12 months post-PJD. Results Pre-clinically, positive impacts with PJD on glucose homeostasis, cholesterol, and body composition versus sham control were demonstrated. Clinically, PJD was performed successfully without serious complications. Twelve months post-surgery, the mean (SD) reduction from baseline in HbA1c was 2.3% (1.3) (p<0.01). Conclusions PJD may provide an anatomy sparing, low-risk, intervention for poorly controlled T2DM without significant alteration of the patient’s lifestyle. The proof-of-concept study is limited by a small sample size and advanced disease, with 80% of participants on insulin and a mean time since diagnosis of over 10 years. Further study is warranted. Trial registration number NCT02283632; Pre-results.

Insulin sensitivity and secretion in obese Type 2 diabetic women after various bariatric operations

Objective: To compare the effects of biliopancreatic diversion (BPD) and laparoscopic gastric banding (LAGB) on insulin sensitivity and secretion with the effects of laparoscopic gastric plication (P). Methods: A total of 52 obese women (age 30-66 years) suffering from type 2 diabetes mellitus (T2DM) were prospectively recruited into three study groups: 16 BPD; 16 LAGB, and 20 P. Euglycemic clamps and mixed meal tolerance tests were performed before, at 1 month and at 6 months after bariatric surgery. Beta cell function derived from the meal test parameters was evaluated using mathematical modeling. Results: Glucose disposal per kilogram of fat free mass (a marker of peripheral insulin sensitivity) increased significantly in all groups, especially after 1 month. Basal insulin secretion decreased significantly after all three types of operations, with the most marked decrease after BPD compared with P and LAGB. Total insulin secretion decreased significantly only following the BPD. Beta cell glucose sensitivity did not change significantly post-surgery in any of the study groups. Conclusion: We documented similar improvement in insulin sensitivity in obese T2DM women after all three study operations during the 6-month postoperative follow-up. Notably, only BPD led to decreased demand on beta cells (decreased integrated insulin secretion), but without increasing the beta cell glucose sensitivity.

Current Guidelines of Bariatric Surgery in Adolescents

For rather a long time, obesity problem in adolescents and children was largely ignored, or at best underestimated. This applies to both the potential health consequences and obesity tracking in adulthood and effective treatment.