Marina Kurian

Systematic review on reoperative bariatric surgery: American Society for Metabolic and Bariatric Surgery Revision Task Force.

BACKGROUND Reoperative bariatric surgery has become a common practice in many bariatric surgery programs. There is currently little evidence-based guidance regarding specific indications and outcomes for reoperative bariatric surgery. A task force was convened to review the current evidence regarding reoperative bariatric surgery. The aim of the review was to identify procedure-specific indications and outcomes for reoperative procedures. METHODS Literature search was conducted to identify studies reporting indications for and outcomes after reoperative bariatric surgery. Specifically, operations to treat complications, failed weight loss, and weight regain were evaluated. Abstract and manuscript reviews were completed by the task force members to identify, grade, and categorize relevant studies. RESULTS A total of 819 articles were identified in the initial search. After review for inclusion criteria and data quality, 175 articles were included in the systematic review and analysis. The majority of published studies are single center retrospective reviews. The evidence supporting reoperative surgery for acute and chronic complications is described. The evidence regarding reoperative surgery for failed weight loss and weight regain generally demonstrates improved weight loss and co-morbidity reduction after reintervention. Procedure-specific outcomes are described. Complication rates are generally reported to be higher after reoperative surgery compared to primary surgery. CONCLUSION The indications and outcomes for reoperative bariatric surgery are procedure-specific but the current evidence does support additional treatment for persistent obesity, co-morbid disease, and complications.

Long-term outcomes after Roux-en-Y gastric bypass: 10- to 13-year data

BACKGROUND Short- and mid-term data on Roux-en-Y gastric bypass (RYGB) indicate sustained weight loss and improvement in co-morbidities. Few long-term studies exist, some of which are outdated, based on open procedures or different techniques. OBJECTIVES To investigate long-term weight loss, co-morbidity remission, nutritional status, and complication rates among patients undergoing RYGB. SETTING An academic, university hospital in the United States. METHODS Between October 2000 and January 2004, patients who underwent RYGB≥10 years before study onset were eligible for chart review, office visits, and telephone interviews. Revisional surgery was an endpoint, ceasing eligibility for study follow-up. Outcomes included weight loss measures and rates of co-morbidity remission, complications, and nutritional deficiencies. RESULTS RYGB was performed in 328 patients with a mean preoperative body mass index of 47.5 kg/m(2). Of 294 eligible patients, 134 (46%) were contacted for follow-up at ≥ 10 years (10+Year follow-up). Mean percentage excess weight loss (%EWL) was 58.9% at 10+Year. Higher %EWL was achieved by non-super-obese versus super-obese (61.3% versus 52.9%, P = .034). Blood pressure, lipid panel, and hemoglobin A1c improved significantly. At 10 years, remission of co-morbidities was 46% for hypertension and hyperlipidemia and 58% for diabetes mellitus. Thirty patients (9%) had revisional surgery for weight regain. Sixty-four patients (19.5%) had long-term complications requiring surgery. All-cause mortality was 2.7%. Nutritional deficiencies were seen in 87% of patients. CONCLUSIONS Weight loss after RYGB appears to be significant and sustainable, especially in the non-super-obese. Co-morbidities are improved, with a substantial number in remission a decade later. Nutritional deficiencies are almost universal.

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.

Evaluating gastric erosion in band management: An algorithm for stratification of risk

BACKGROUND Laparoscopic gastric banding has several known complications, including gastric erosion. No clear factors have been determined for the development of band erosion, but technical factors such as covering the buckle of the band have been implicated. The objective of the present study was to determine whether band management after surgery, band size, or filling beyond the manufacturer-determined maximal volume has an effect on the incidence of erosion at a university hospital in the United States. METHODS We performed a retrospective review of a prospective institutional review board-approved database. All patients who had been followed from 2002 to 2008 were identified. The maximal band volume was 4 cm(3) for the 9.75-cm/10-cm band and 10 cm(3) for the Vanguard band. The bands were considered overfilled if they had been filled to greater than the maximal volume for >/=3 months. RESULTS A total of 2437 patients had undergone Lap-Band surgery. Of these 2437 patients, 14 developed erosion (.57%). The primary erosion rate was .39% (9 of 2359). These patients were divided into 3 groups according to the type of band placed: group 1, Vanguard (n = 735); group 2, 9.75-cm/10-cm band (n = 1624); and group 3, revisions to Vanguard, including a band placed around a bypass (n = 78). The incidence of gastric erosion by group was .95% (7 of 735) in group 1, .12% (2 of 1624) in group 2, and 6.41% (5 of 78) in group 3. The difference in the erosion rate among the groups was significant (group 1 versus 2, P = .005; group 3 versus 1, P = .003; and group 3 versus 2, P = .001). Erosions developed in each group without overfilling. Also, comparing the erosion rate in the overfilled versus underfilled bands, statistical significance was found only for group 1 at 3.18% versus .35% (P = .006). The erosion rate in the overfilled versus underfilled was 1.01% versus .07% in group 2 and 11.11% versus 3.92% in group 3. CONCLUSION A band that needs to be overfilled might be a sign of erosion, and patients should undergo endoscopy. Band revision has a greater rate of erosion than primary banding. The Vanguard band has a greater risk of erosion than the 4-cm(3) bands.

Bariatric surgery: an overview of obesity surgery.

We are in the midst of an obesity epidemic. More than 50 percent of adults are obese or overweight. Approximately 6 percent of adults are so vastly overweight that they have a condition called morbid obesity, meaning that their weight problem is so severe that it is life threatening. Perhaps even more concerning is the increasing prevalence of childhood and teenage obesity. The problem is so severe that obesity and a sedentary lifestyle have become the most concerning health care issue in westernized society. Next to smoking, obesity is the second leading cause of preventable death.1 Unfortunately, obesity is far more dangerous than most realize. The actual definition of obesity is excess adiposity or fat tissue. Adults with a body mass index of 30 or higher and children at the 95th percentile of body mass index are considered to be obese.1,2 The increased amount of fat tissue causes numerous medical problems. Obesity is a contributory cause for diabetes in more than 80 percent of diabetics. It is responsible for the vast majority of sleep apnea. Obesity causes hypertension and hypercholesterolemia. It leads to premature arthritis. Obesity can cause menstrual irregularities, infertility, and an increased rate of miscarriage in women.3 No organ system is spared the detrimental effects caused by excess fat tissue. Despite these alarming facts and the significant economic burden placed on the health care system, obesity remains undertreated. Often people are told that they are healthy, except for their obesity. Would one say that someone is healthy except for their diabetes? Most physicians treat obesity by telling people to lose weight. This strategy has obviously failed, and as a society we are heavier than we have ever been. Treatment options for obesity remain limited. Behavioral modification and dietary counseling rarely are successful for adults with chronic severe obesity.4 When caloric intake is reduced, the body interprets this signal as a sign of stress or reduced availability of food. The body goes into a conservation mode, reducing its metabolic rate, opposing weight loss. Thus, after a sharp decrease in weight for the first few weeks, the patient’s weight stabilizes. The patient gets discouraged and rapidly returns to his or her baseline eating habits. Weight Watchers, Jennie Craig, and NutriSystem are examples of niche food companies, and have never demonstrated substantial weight loss in morbidly obese adults. Currently, there are three pharmaceuticals approved for the treatment of obesity in the United States. They are phentermine, sibutramine (Meridia; Abbott Laboratories, Inc., Abbott Park, Ill.), and orlistat (Xenical; Hoffmann-La Roche, Inc., Nutley, N.J.). On average, they result in 8 percent of body weight lost, compared with 4 percent with diet and exercise alone.5 There are numerous drugs in the drug companies pipeline, but only two, Axokine (Regeneron Pharmaceuticals, Inc., Tarrytown, N.Y.) and Rimonibant (SanofiAventis, Paris, France), are in phase III studies. At this time, there is no “miracle” drug for weight loss. It is likely that the treatment of obesity will require long-term use of a cocktail of pharmaceuticals over an extended, if not indefinite, period of time. Clearly, the most appealing may be the combined use of medications and simple medical devices, working in tandem. From the Department of Plastic Surgery, Albert Einstein College of Medicine, and the Department of Surgery, Lenox Hill Hospital. Received for publication June 21, 2006; accepted October 18, 2006. Copyright ©2007 by the American Society of Plastic Surgeons

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.

White Paper AGA: POWER — Practice Guide on Obesity and Weight Management, Education, and Resources

&NA; The epidemic of obesity continues at alarming rates, with a high burden to our economy and society. The American Gastroenterological Association understands the importance of embracing obesity as a chronic, relapsing disease and supports a multidisciplinary approach to the management of obesity. Because gastrointestinal disorders resulting from obesity are more frequent and often present sooner than type 2 diabetes mellitus and cardiovascular disease, gastroenterologists have an opportunity to address obesity and provide an effective therapy early. Patients who are overweight or obese already fill gastroenterology clinics with gastroesophageal reflux disease and its associated risks of Barrett’s esophagus and esophageal cancer, gallstone disease, nonalcoholic fatty liver disease/nonalcoholic steatohepatitis, and colon cancer. Obesity is a major modifiable cause of diseases of the digestive tract that frequently goes unaddressed. As internists, specialists in digestive disorders, and endoscopists, gastroenterologists are in a unique position to play an important role in the multidisciplinary treatment of obesity. This American Gastroenterological Association paper was developed with content contribution from Society of American Gastrointestinal and Endoscopic Surgeons, The Obesity Society, Academy of Nutrition and Dietetics, and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, endorsed with input by American Society for Gastrointestinal Endoscopy, American Society for Metabolic and Bariatric Surgery, American Association for the Study of Liver Diseases, and Obesity Medicine Association, and describes POWER: Practice Guide on Obesity and Weight Management, Education and Resources. Its objective is to provide physicians with a comprehensive, multidisciplinary process to guide and personalize innovative obesity care for safe and effective weight management.

Sustained weight loss after gastric banding revision for pouch-related problems.

Objective:To assess the impact of revisional surgery after laparoscopic adjustable gastric banding (LAGB) on weight loss at 12 and 24 months. Background:There is no uniform consensus as to the optimal procedure for patients requiring revision after LAGB. Few studies address the issue of weight loss after band salvage procedures, despite this being a critical factor in deciding which reoperative procedure to choose. Methods:A retrospective analysis was conducted of adult patients who underwent LAGB from January 1, 2001 to June 30, 2009 at a single institution. Patients who required revision for pouch-related problems including band slippage, pouch dilation, and hiatal hernia were studied. Demographic data, body mass index (BMI), percentage excess weight loss (% EWL), and operative details were recorded. Weights were recorded at 12 and 24 months after revision. These were compared with initial weight, weight before revision, and weight in patients who did not have a reoperation. Results:Of 3876 patients, 390 patients were included in analysis of weight outcomes after revision. The procedure-related mortality was 0%. Early (30-day) complications occurred in 0.5%, late complications (erosion) in 0.5%, and 29 patients (7.4%) required a second revision. For patients undergoing revision, the initial weight was 124.06 ± 21.28 kg and BMI was 44.80 ± 6.12 kg/m2. At reoperation, weight was 89.18 ± 20.51 kg, BMI was 32.25 ± 6.50 kg/m2 and, %EWL was 54.13 ± 21.80%. Twelve months postrevision, weight was 92.24 ± 20.22 kg, BMI was 33.32 ± 6.41 kg/m2, and %EWL was 48.81 ± 22.71%. Weight was 92.42 ± 19.91 kg, BMI was 33.53 ± 6.25 kg/m2, and %EWL was 47.50 ± 22.91% twenty-four months postrevision. Conclusions:Reoperation for pouch-related problems after LAGB is safe and effective. Weight loss is maintained after reoperation.