Mauro Toppino

Mortality after bariatric surgery: analysis of 13,871 morbidly obese patients from a national registry.

Objective:To define mortality rates and risk factors of different bariatric procedures and to identify strategies to reduce the surgical risk in patients undergoing bariatric surgery. Summary Background Data:Postoperative mortality is a rare event after bariatric surgery. Therefore, comprehensive data on mortality are lacking in the literature. Methods:A retrospective analysis of a large prospective database was carried out. The Italian Society of Obesity Surgery runs a National Registry on bariatric surgery where all procedures performed by members of the Society should be included prospectively. This Registry represents at present the largest database on bariatric surgery worldwide. Results:Between January 1996 and January 2006, 13,871 bariatric surgical procedures were included: 6122 adjustable silicone gastric bandings (ASGB), 4215 vertical banded gastroplasties (VBG), 1106 gastric bypasses, 1988 biliopancreatic diversions (BPD), 303 biliointestinal bypasses, and 137 various procedures. Sixty day mortality was 0.25%. The type of surgical procedure significantly influenced (P < 0.001) mortality risk: 0.1% ASGB, 0.15% VBG, 0.54% gastric bypasses, 0.8% BPD. Pulmonary embolism represented the most common cause of death (38.2%) and was significantly higher in the BPD group (0.4% vs. 0.07% VBG and 0.03% ASGB). Other causes of mortality were the following: cardiac failure 17.6%, intestinal leak 17.6%, respiratory failure 11.8%, and 1 case each of acute pancreatitis, cerebral ischemia, bleeding gastric ulcer, intestinal ischemia, and internal hernia. Therefore, 29.4% of patients died as a result of a direct technical complication of the procedure. Additional significant risk factors included open surgery (P < 0.001), prolonged operative time (P < 0.05), preoperative hypertension (P < 0.01) or diabetes (P < 0.05), and case load per Center (P < 0.01). Conclusions:Mortality after bariatric surgery is a rare event. It is influenced by different risk factors including type of surgery, open surgery, prolonged operative time, comorbidities, and volume of activity. In defining the best bariatric procedure for each patient the different mortality risks should be taken into account. Choice of the procedure, prevention, early diagnosis, and therapy for cardiovascular complications may reduce postoperative mortality.

Progress in Implantable Gastric Stimulation: Summary of Results of the European Multi-Center Study

BackgroundThe Implantable Gastric Stimulator (IGS®), a pacemaker-like device, has been found to be safe and effective to induce and maintain weight loss. The LOSS (Laparoscopic Obesity Stimulation Survey) is a prospective non-randomized trial which enrolled 69 patients involving 11 investigator centers in 5 European Countries. In 19 patients, ghrelin was analyzed.MethodsBetween January 2002 and December 2003, 69 patients (F/M 49/20), mean age 41 years (18–65) underwent IGS implantation. Mean BMI was 41 (35–57), mean weight 115.0 kg (65–160) and mean excess weight (EW) 52 kg (13–89). The IGS was actived 30 days after implantation. In a subset of 19 patients studied further, 0, 6, and 12 months appetite and satiety score were evaluated and 0 and 6 months ghrelin profile was analyzed.ResultsThe mean ± standard error %EWL was: 8.6±1.8 at 1 month, 15.8±2.3 at 3 months, 17.8±2.6 at 6 months, 21.0±3.5 at 10 months, and 21.0±5.0 at 15 months. There were no intraoperative surgical or long-term complications. 7 intra-operative gastric penetrations occurred, observed by gastroscopy, without sequelae. 1 patient required a reoperation to remove a retained lead needle. In the subset of 19 patients, appetite was reduced and post-prandial and inter-prandial satiety was increased after IGS implantation. In the 19 patients, despite weight reduction, ghrelin did not increase.ConclusionIGS can be implanted laparoscopically with minimal perioperative complications. Appetite is reduced and satiety is increased after the implantation. Ghrelin levels could be one of the mechanisms explaining weight loss and weight maintenance in IGS patients. If weight loss is maintained, IGS could be considered a good option for selected patients.

Laparoscopic Adjustable Silicone Gastric Banding Versus Vertical Banded Gastroplasty in Morbidly Obese Patients: A Prospective Randomized Controlled Clinical Trial

Objective: To compare, in a prospective, randomized, single-institution trial laparoscopic adjustable silicone gastric banding (LASGB) with laparoscopic vertical banded gastroplasty (LVBG) in morbidly obese patients. Summary Background Data: LASGB is a simple and safe procedure, but some reports have suggested disappointing long-term results. Despite the recent widespread use of LASGB, there are no prospective nor randomized trials comparing LASGB with other laparoscopic procedures. Methods: A total of 100 morbidly obese patients, with body mass index (BMI) 40 to 50 kg/m2, without compulsive eating, were randomized to either LASGB (n = 49) or LVBG (n = 51). Minimum follow-up was 2 years (mean 33.1 months). Results: There were no deaths or conversions in either group. Mean operative time was 94.2 minutes in LVBGs and 65.4 in LASGBs (P < 0.05). Early morbidity rate was lower in LASGBs (6.1%) versus LVBGs (9.8%) (P = 0.754). Mean hospital stay was shorter in LASGBs versus LVBGs: 3.7 days versus 6.6 (P < 0.05). Late complications rate in LVBGs was 14% (7 of 50) and in LASGBs 32.7% (16 of 49) (P < 0.05). The most frequent complication was the slippage of the band (18%). Late reoperations rate in LVBGs was 0% (0 of 50) versus 24.5% (12 of 49) in LASGBs (P < 0.001). Excess weight loss in LVBGs was, at 2 years, 63.5% and, at 3 years, 58.9%; in LASGBs, excess weight loss, respectively, was 41.4% and 39%. BMI in LVBGs was, at 2 years, 29.7 kg/m2 and, at 3 years, 30.7 kg/m2; in LASGBs, BMI was 34.8 kg/m2 at 2 years and 35.7 kg/m2 at 3 years. According to Reinholds classification, a residual excess weight <50% was achieved, at 2 years, in 74% of LVBG and 35% of LASGB (P < 0.001). Conclusions: This study demonstrates that, in patients with BMI 40 to 50 kg/m2, LASGB requires shorter operative time and hospital stay but LVBG is more effective in terms of late complications, reoperations, and weight loss.

Esophagogastric cancer after bariatric surgery: systematic review of the literature

BACKGROUND Because the number of patients with a previous bariatric procedure continues to rise, it is advisable for bariatric surgeons to know how to manage the rare event of the development of an esophagogastric cancer. The aim of the study was to perform a systematic review of all reported cases of esophagogastric cancers after bariatric surgery. METHODS Systematic review of English and French written literature in MEDLINE and EMBASE database. RESULTS Globally, 28 articles describing 33 patients were retrieved. Neoplasms were diagnosed at a mean of 8.5 years after bariatric surgery (range 2 months-29 years). There were 11 esophageal and 22 gastric cancers; although adenocarcinoma represented most cases (90.6%), a tubulovillous adenoma with high-grade atypia, an intramural gastrointestinal stromal tumor, and a diffuse large B-cell lymphoma of the gastric fundus were also reported. Node involvement was reported in 14 cases, and distal metastases in 5. The most frequently reported symptoms were dysphagia and food intolerance, vomiting, epigastric pain, and weight loss. Surgery was performed in 28 patients, although 4 underwent only chemotherapy and/or radiotherapy and 1 received palliative care. Reported mortality rate was 48.1%. CONCLUSIONS To date, it is not possible to quantify the incidence of esophagogastric cancer after bariatric surgery because of the paucity of reported data. Nevertheless, because the main concern is the delay in diagnosis, it is of critical importance to carefully evaluate any new or modified upper digestive tract symptom occurring during bariatric surgery follow-up.

Age as a long-term prognostic factor in bariatric surgery.

Objective:To analyze the potential effects of preoperative age on postoperative weight loss in patients who underwent Roux-en-Y gastric bypass (RYGBP) with long-term follow-up data. Background:The reasons for individual differences in surgically induced weight loss are not completely understood. To date, there are no available studies specifically aimed at analyzing the effects of age on weight loss in patients undergoing the same operation and with long-term follow-up data. Methods:Retrospective analysis of prospectively collected data for all patients who underwent RYGBP between 2006 and 2010. To evaluate weight loss, we used preoperative and follow-up body mass index (BMI), analyzed by the mixed-effects linear model for repeated measures. To evaluate age effects, patients were classified in quartiles (⩽35 years, 36–42 years, 43–51 years, ≥52 years). Results:A total of 489 patients entered the study; preoperatively, the younger group showed a significantly higher BMI (mean BMI: 48.2 in patients aged ⩽35 years, 46.9 in 36–42 years, 45.5 in 43–51 years, 45.7 in ≥52 years, P = 0.014) and a higher percentage of super-obesity (41.6% among patients aged ⩽35 years, 28.1% among 36–42 years, 27.6% among 43–51 years, 28.3% among ≥ 52 years, P = 0.047). In spite of this, younger patients experienced a significantly greater and prolonged BMI decrease during the entire follow-up period and the BMI trend over time resulted significantly modified according to age quartiles (P = 0.036). Conclusions:This study provides a new prognostic factor in bariatric surgery: patient age. Because advanced age represents a risk factor for complications and mortality, and given that bariatric surgery may not be as effective in older patients compared to younger subjects, we believe that surgical indications in patients older than 50 years should be carefully weighed up.

The role of early radiological studies after gastric bariatric surgery.

Background: The authors investigated early radiological findings after gastric surgery for morbid obesity to evaluate their usefulness in avoiding complications or facilitating treatment. Material and Methods: 413 patients underwent gastric bariatric surgery: 327 had vertical banded gastroplasty (VBG), 55 Roux-en-Y gastric bypass (RYGBP), 22 adjustable silicone gastric banding (ASGB), and 9 biliopancreatic diversion (BPD). A radiological upper gastrointestinal investigation employing water-soluble contrast medium was perform ed in each patient between the 2nd and 8th postoperative day. Several techniques were employed to assess different radiological findings related to the anatomic modifications after the bariatric surgery. Results: In VBGs, delayed emptying was found in 10 patients (3%), gastric leak in 3 patients (0.9%), vertical suture breakdown in 1 patient (0.3%), and a wide pouch in 4 patients (1.2%). In RYGBP, a leak was detected in 2 patients (3.6%), delayed emptying in 2 (3.6%), and a wide pouch in 5 (9.1%). ASGB required band enlargement for stomal stenosis in 6 patients (27.2%). Temporary delayed emptying from stomal stenosis was also observed in 2 BPDs (22.2%). Overall complications were 35/413 (8.2%). Two cases of gastric leak after VBG were reoperated. Stomal stenosis after ASGB was treated by percutaneous band deflation; other cases were medically treated until complete healing. Conclusions: Early radiological study after gastric bariatric surgery is advisable, since it detected post operative complications (gastric perforation, stomal stenosis, etc.) and modified the clinical approach. As the interpretation of these radiographs is often difficult, involving different projections or patients positions or other technical managements, surgeons and radiologists must interact and be knowledgable.

Clinical Evaluation of Fibrin Glue in the Prevention of Anastomotic Leak and Internal Hernia after Laparoscopic Gastric Bypass: Preliminary Results of a Prospective, Randomized Multicenter Trial

Background: Gastro-jejunal anastomotic leak and internal hernia can be life-threatening complications of laparoscopic Roux-en-Y gastric bypass (LRYGBP), ranging from 0.1-4.3% and from 0.8-4.5% respectively. The safety and efficacy of a fibrin glue (Tissucol®) was assessed when placed around the anastomoses and over the mesenteric openings for prevention of anastomotic leaks and internal hernias after LRYGBP. Methods: A prospective, randomized, multicenter, clinical trial commenced in January 2004. Patients with BMI 40-59 kg/m2, aged 21-60 years, undergoing LRYGBP, were randomized into: 1) study group (fibrin glue applied on the gastro-jejunal and jejuno-jejunal anastomoses and the mesenteric openings); 2) control group (no fibrin glue, but suture of the mesenteric openings). 322 patients, 161 for each arm, will be enrolled for an estimated period of 24 months. Sex, age, operative time, time to postoperative oral diet and hospital stay, early and late complications rates are evaluated. An interim evaluation was conducted after 15 months. Results: To April 2005, 204 patients were randomized: 111 in the control group (mean age 39.0±11.6 years, BMI 46.4±8.2) and 93 in the fibrin glue group (mean age 42.9±11.7 years, BMI 46.9±6.4). There was no mortality or conversion in both groups; no differences in operative time and postoperative hospital stay were recorded. Time to postoperative oral diet was shorter for the fibrin glue group (P=0.0044). Neither leaks nor internal hernias have occurred in the fibrin glue group. The incidence of leaks (2 cases, 1.8%) and the overall reoperation rate were higher in the control group (P=0.0165). Conclusion: The preliminary results suggest that Tissucol® application has no adverse effects, is not time-consuming, and may be effective in preventing leaks and internal hernias in morbidly obese patients undergoing LRYGBP.

Laparoscopic vertical banded gastroplasty for morbid obesity. Assessment of efficacy.

AbstractsBackground: The advantages of treating morbidly obese patients via the laparoscopic approach have been demonstrated, in particular, for adjustable silicone gastric banding, but this operation is associated with a high rate of late complications. Gastric bypass and malabsorbitive procedures are feasible via the laparoscopic approach, but they entail a prolonged operating time and a consistently high morbidity rate. Laparoscopic vertical banded gastroplasty represents an effective alternative. Methods: We performed 250 consecutive LVBG between November 1995 and February 2000. The procedure consisted of a personal technique designed to reproduce, by laparoscopy, MacLeans modification of the standard open Mason vertical-banded gastroplasty, with a calibrated transgastric window, a complete division between the staple lines, and a 5-cm–circumference polypropylene collar. Results: The operative time was 95 min and the conversion rate was 0.8%. Operative mortality was nil; early and late complications, respectively, were 4.4% and 4%; the reoperation rate was 2%. Global results at 4 years were as follows: excess weight loss (EWL) 61%, success rate (excess weight <50%) 76.9%, body mass index (BMI) 29.4 kg/m2. In morbidly obese patients, the EWL at 4 years was 62.2%, with a 77.4% success rate and a 28.4 kg/m2 BMI; in superobese patients, the EWL at 4 years was 54.9% with a 50% success rate and a 35.5 kg/m2 BMI. The overall follow-up rate was 92%. Conclusions: LVBG is an effective and safe operation in morbidly obese patients, providing good weight loss with a low morbidity rate, no mortality, and minimum discomfort. However, in superobese patients, the weight loss results are disappointing; in these patients, LVBG is questionable and more complex procedures should be considered.

Staple-line Disruptions in Vertical Banded Gastroplasty Related to Different Stapling Techniques

We performed one or more upper G. I. barium single-contrast studies on 125 out of 166 Mason vertical banded gastroplasty (VBG) operated patients (total: 226 X-ray examinations during a 3 month-10 year postoperative period). Forty four patients had a staple-line performed by double application of a 2-row stapler with manual reinforcement (group 1); 12 had a single application of a 4-row stapler with reinforcement (group 2); the last 69 patients had a partition with a 4-row stapler without reinforcement (group 3). A staple-line disruption was observed in 34 cases (27.2%); 17/44 (38.6%) cases belong to group 1, 6/12 cases (50%) to group 2 and 11/69 cases (15.9%) to group 3. The range of breakdowns diameter was 2-30 mm (nine cases double, one case quadruple). In 16 out of 34 cases we observed a preferential contrast pathway through the perforations. In 23 cases we noted a weight regain and in one case an initial failure on weight loss; in 12 cases the excess weight loss (EWL) was less than 30%. In group 3, we found two tiny perforations at the top of the partition, but another nine along with the staple-lines. In our experience, staple line disruptions are only reduced using the 4-row stapler without reinforcement; even with this stapling technique late breakdowns along the staple-line, not only at the apex of the partition, can occur.

10-year follow-up of laparoscopic vertical banded gastroplasty. Good results in selected patients

Objective:To evaluate the long-term results of laparoscopic vertical banded gastroplasty (VBG) for morbid obesity. Background:Laparoscopic VBG, a safe and straightforward bariatric procedure characterized by good short-term results, has been progressively replaced by other more complex procedures on the basis of a presumed high rate of long-term failure. Nevertheless, some authors have recently reported long-term efficacy in selected patients. Methods:All patients who underwent laparoscopic VBG were included in a prospective database. Patients reaching 10-year follow-up received a complete evaluation including clinical, endoscopic, and biochemical examinations. Results:Between January 1996 and March 1999, 266 morbidly obese patients underwent bariatric procedures. Among them, 213 were selected for laparoscopic VBG; exclusion criteria were as follows: contraindications to pneumoperitoneum, gastroesophageal reflux disease, and psychological contraindications to restrictive procedures. Mean age, preoperative weight, and body mass index were 36.9 years, 123.6 kg, and 45.4 kg/m2, respectively. Intraoperative complication rate and conversion rate were 0.9% and 0.9%, respectively. Early postoperative complication rate was 4.2% and early reoperation rate was 0.5%. Mean hospital length of stay was 6.3 days. Mortality was nil. The 10-year follow-up rate was 70.4% (150 patients). Late postoperative complication rate was 14.7%, and 10-year revisional surgery rate was 10.0%. The excess weight loss percentages at 3, 5, and 10 years were 65.0%, 59.9%, and 59.8%, respectively. The resolution and/or improvement rate for comorbidity were 47.5% for hypertension, 55.6% for diabetes, 75% for sleep apnea, and 47.4% for arthritis. Mean Moorehead-Ardelt Quality of Life Questionnaire and BAROS values were 1.4 and 3.8, respectively. Conclusions:The present study demonstrates that laparoscopic VBG in carefully selected patients leads to long-term results comparable with more complex and invasive procedures. Given the low postoperative morbidity for laparoscopic VBG, its present clinical role should be, in our opinion, reevaluated.