Ming-Che Hsin

Bariatric surgery in old age: a comparative study of laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy in an Asia centre of excellence.

Abstract Bariatric surgery has been proved to be the safest and efficient procedure in treating morbid obese patients, but data is still lacking in the elderly population. The aim of our study was to compare the safety and efficacy of laparoscopic Roux–en-Y gastric bypass (LRYGB) and sleeve gastrectomy (LSG) in patients aged more than 55 years. We performed a retrospective review of a prospectively collected database. All patients with body mass index (BMI) ≧32 kg/m2 and aged more than 55 years undergoing LRYGB or LSG in BMI Surgery Centre, E-Da Hospital between January 2008 and December 2011 with at least one year of follow up were included for the analysis. Demography, peri-operative data, weight loss and surgical complications were all recorded and analyzed. Mean age and BMI of these 68 patients (22 males and 46 female) were 58.8 years (55–79 years) and 39.5 kg/m2 (32.00–60.40 kg/m2). LRYGB was performed in 44 patients and LSG in 24 patients. The two groups were comparable in their preoperative BMI, American Society of Anaesthesia (ASA) score and gender distribution. LSG patients were significantly older than patients receiving LRYGB. The proportion of type 2 diabetes preoperatively was significantly higher in LRYGB patients as compared to LSG patients (88.63% vs. 50%; P < 0.01). The prevalence of other co-morbidities was similar and comparable between the groups. Mean BMI in the LRYGB and LSG groups at the end of 1 year were 28.8 kg/m2 and 28.2 kg/m2, respectively, and there was no statistically significant difference in mean percentage of excess weight loss (%EWL) at 1 year. The percentage of resolution of diabetes was significantly higher in LRYGB (69.2%) as compared to LSG (33.3%). On the other hand, there was no statistical difference in the percentage of resolution of hypertension, hyperlipidemia and fatty liver hepatitis. The overall morbidity and re-operation rate was higher in LRYGB patients. In morbidly elderly patients, both surgeries achieved good weight loss and resolution of comorbidities. LRYGB is superior to LSG in terms of diabetes remission but carries higher complication rates even at high volume centres.

A case-matched study of the differences in bone mineral density 1 year after 3 different bariatric procedures.

BACKGROUND Studies have reported decreased bone mineral density (BMD) after laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). Laparoscopic adjustable gastric banded plication (LAGBP) is a novel procedure resulting in a dual restrictive mechanism of weight loss without altering gastrointestinal anatomy. The objectives of this study were to compare the BMD changes at 1 year after LAGBP, LSG, and LRYGB. METHODS The sample included 120 patients (40 patients [13 men/27 premenopausal women] each in LAGBP, LSG, and LRYGB groups). The mean preoperative age and body mass index were 30.0±6.5 years and 39.5±3.8 kg/m2, respectively. BMD was measured using dual energy X-ray absorptiometry at the lumbar anteroposterior spine and total hip preoperatively and 1 year postoperatively. RESULTS The mean percentage of excess weight loss was 61.9%±16.8%, 77.1%±12.3%, and 72.7%±17.4% at 1 year after LAGBP, LSG, and LRYGB, respectively. The mean BMD at the lumbar anteroposterior spine remained unchanged in the LSG and LRYGB groups, but significantly increased in the LAGBP group. The mean BMD at the total hip significantly decreased in all groups compared to the preoperative values. However, the mean BMD was significantly higher in the LRYGB than in the LAGBP group. CONCLUSION Bone loss at the hips was observed in all patients, including those with adequate micronutrient supplementation. LRYGB caused significantly greater bone loss than the other procedures.

Management of gastric fold herniation after laparoscopic adjustable gastric banded plication: a single-center experience☆

BACKGROUND Laparoscopic adjustable gastric banded plication (LAGBP) is a novel bariatric procedure, and little is known about its potential complications. OBJECTIVES Herein, we report on complications of LAGBP and discuss the clinical features and diagnostic and therapeutic strategies in such situations, with emphasis on gastric fold herniation (GFH). SETTING University Hospital. METHODS Prospectively collected data of 223 patients who underwent LAGBP for morbid obesity between August 2009 and December 2014 were retrospectively analyzed. Follow-up at 1 year was 75%. RESULTS Eight patients (3.5%) required readmission due to major complications, including 1 trocar site hernia, 1 band leak, 1 gastric stenosis, and 5 GFHs. GFHs occurred mostly in the first postoperative month (4/5, 80%) and at the fundus (5/5, 100%); 4 GFHs occurred in the initial 70 patients. Seven laparoscopic reoperations were required for managing GFH. The gastric band was removed in 3 patients (of 5; 60%). Two patients developed residual intra-abdominal abscess and were treated successfully by image-guided drainage. In March 2012, we reversed the order of our surgical techniques for the subsequent 153 patients and performed greater curvature plication first, followed by band placement. Only one GFH occurred after this change in surgical order (1/153 versus 4/70; P< .05). CONCLUSIONS High clinical suspicion assisted by radiological investigations and early surgical intervention is the key for managing GFH after LAGBP. Though GFH complications were rare, we significantly reduced its occurrence by altering the surgical order in LAGBP to plication followed by banding.

Single Incision LRYGB

Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) has emerged as a gold standard bariatric procedure. In the pursuit of scarless surgery, the concept of single incision laparoscopic surgery (SILS) was born and implicated in bariatric surgery. To hide the scar, umbilicus serves as the main orifice for entry of all ports in SILS. However, this small incision leads to change of basic laparoscopic principles of port placement and makes procedure exceptionally difficult. To perform single incision transumbilical (SITU) LRYGB, proper case selection important. Extremely obese patients (BMI >50 kg/m2) and very tall patients (>180 cm in height) should be avoided because of abundant visceral fat and the long distance between umbilicus and gastric pouch. Previous abdominal surgery is a relative-contraindication because of lost advantage of cosmesis. During early learning curve stage, the 4.5 cm skin incision can be enlarged to 6 cm omega shaped incision, to get extra room for instrument maneuverability. Umbilicoplasty can be done to decrease this to 3.5 cm at the end of the procedure. Furthermore, in morbidly obese patients, the hypertrophic liver usually hinders the surgeon’s view of upper stomach and liver retraction plays a pivotal role in the success of surgery. Liver suspension technique provides good exposure. After adequate experience, all steps of multi-port LRYGB can be readily replicated in SITU-LRYGB, without increased complication rate but with improved cosmetic result.