Sylvia Weiner

Failure of Laparoscopic Sleeve Gastrectomy – Further Procedure?

Background: Worldwide, the incidence of morbid obesity is increasing, and surgery is the only effective longterm treatment. Laparoscopic sleeve gastrectomy (LSG) is associated with acceptable weight loss and reduced comorbidities. It is considered a safe procedure with sporadic complications. This publication aims to describe failures of LSG in terms of ineffective weight loss or early weight regain, and analyze secondary treatment options. Methods: From October 2001 to December 2010, 937 patients underwent LSG in our department. Initially, all procedures were scheduled as a two-stage procedure (LSG followed by biliopancreatic diversion with duodenal switch). However, the second procedure was not performed in 64 patients (body mass index > 60 kg/m2). Since 2005, the frequency of second stage procedures after weight regain has been increasing; their outcome is analyzed. Results: Of the 937 patients, 17 (1.8%) experienced staple line leakage. Mean time to first reintervention or endoscopic stent placement was 15.6 ± 22 days (range 2–78). From 2005 to 2010, 106 secondary procedures were performed. Insufficient weight loss or weight regain were the indications in 88 cases. Sixteen (15%) patients had severe gastroesophageal reflux which was resolved by Roux-en-Y gastric bypass (RYGB). Stenosis was observed in 2 (2.6%) patients, which required endoscopic dilatation and stent placement in one case and gastric bypass in the other. Conclusions: LSG is a feasible and popular bariatric procedure. Mortality (0.4%) was much higher than after gastric bypass (0.03%) and gastric banding (0%) The knowledge of potential complications and their management is crucial. All restrictive procedures require patient compliance, but increased food uptake after RYGB and LSG is common. Malabsorptive procedures are more effective for long-term weight loss. Duodenal switch and omega-loop gastric bypass are more efficient second stage procedures than re-sleeve or RYGB.

The Bariatric Quality of Life (BQL) Index: A Measure of Well-being in Obesity Surgery Patients

Background: Quality of life (QoL) is considered to be the true measure for the effectiveness of a surgical procedure, but there are only a few validated instruments available for bariatric surgery. Therefore, a new diseasespecific 30-item instrument was created, which was called Bariatric Quality of Life (BQL) questionnaire. Methods: To validate the BQL, we studied 133 patients after 4 different types of bariatric surgery. Initially, mean body mass index (BMI) was 47.2 ±7.6 kg/m2 and mean age was 38.8 ±11.0 years. At baseline, and 1, 6, and 12 months after surgery, patients filled in the BQL, the SF-12 (Short Form of SF-36 Health Survey), the GIQLI (Gastrointestinal Quality of Life Index), and the BAROS (Bariatric Analysis and Reporting Outcome System). Results: Internal consistency of the BQL was found to be good, with Cronbachs alpha ranging between 0.71 and 0.86. Factor analyses suggested that the BQL included a highly consistent set of QoL items and a second part on co-morbidities and gastrointestinal symptoms. At the 12 months follow-up, the BQL was closely correlated to SF 12 (Pearsons r = 0.86), GIQLI (0.68), BAROS (0.71), and excess weight loss (0.55). Standardized effect sizes over time were larger for the BQL (1.39 and 1.58) than for the other instruments. Conclusions: The BQL questionnaire is a validated instrument ready for clinical use.

Mapping Utility Scores from a Disease‐Specific Quality‐of‐Life Measure in Bariatric Surgery Patients

OBJECTIVES To develop algorithms for a conversion of disease-specific quality-of-life into health state values for morbidly obese patients before or after bariatric surgery. METHODS A total of 893 patients were enrolled in a prospective cross-sectional multicenter study. In addition to demographic and clinical data, health-related quality-of-life (HRQoL) data were collected using the disease-specific Moorehead-Ardelt II questionnaire (MA-II) and two generic questionnaires, the EuroQoL-5D (EQ-5D) and the Short Form-6D (SF-6D). Multiple regression models were constructed to predict EQ-5D- and SF-6D-based utility values from MA-II scores and additional demographic variables. RESULTS The mean body mass index was 39.4, and 591 patients (66%) had already undergone surgery. The average EQ-5D and SF-6D scores were 0.830 and 0.699. The MA-IIwas correlated to both utility measures (Spearmans r = 0.677 and 0.741). Goodness-of-fit was highest (R(2) = 0.55 in the validation sample) for the following item-based transformation algorithm: utility (MA-II-based) = 0.4293 + (0.0336 x MA1) + (0.0071 x MA2) + (0.0053 x MA3) + (0.0107 x MA4) + (0.0001 x MA5). This EQ-5D-based mapping algorithm outperformed a similar SF-6D-based algorithm in terms of mean absolute percentage error (P = 0.045). CONCLUSIONS Because the mapping algorithm estimated utilities with only minor errors, it appears to be a valid method for calculating health state values in cost-utility analyses. The algorithm will help to define the role of bariatric surgery in morbid obesity.

Validation of the adapted Bariatric Quality of Life Index (BQL) in a prospective study in 446 bariatric patients as one-factor model.

Background: The Bariatric Quality of Life Index (BQL) was created and validated as a nine-factor model in 2005 for the measurement of quality of life (QoL)inpatients before and after bariatric surgery. Even though the results were acceptable, the statistical structure of the test was very unclear. Methods: A total·f466 patients were enrolled in an ongoing prospective longitudinal German study. The assessment took place preoperatively and at 1, 3, 6, 9, and 12 months postoperatively. After that period, reevaluations were done on a yearly basis. In addition to demographic and clinical data, QoL data were collected using the BQL, the Short Form12 (SF-12v2), the Gastrointestinal Quality of Life Index (GIQLI),and the Bariatric Analysis and Reporting Outcome System (BAROS; old version since the study started in 2001). Statistical parameters for contingency (Cronbach’s Α),construct and criterion validity (Pearson’s r),and responsiveness (standardized effect sizes) were calculated. The data of the assessments conducted preoperatively and after 6 and 12 months were used for the validation. Results: The factor analysis and the screeplot showed that a one-factor solution explained 45.37%of variance. The selectivity of the items ranged between 0.61 and 0.85,and Cronbach’s Α was 0.898. The measurements showed similar excellent results with the analysis of all measurement points. Pearson’s test showed a good retest reliability (r = 0.9). The correlations with the SF-12 and the Moorehead-Ardelt I questionnaire (MA-I) were significant, while the correlation with the GIQLI was low. The results of the correlation with the excess weight loss (EWL)(0.45 and 0.49) and the BMI (–0.38 and –0.47) were good. Conclusion: The BQL is a valid instrument and should be preferred over generic questionnaires as it provides betterresponsiveness.

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.

Quality of Life after Bariatric Surgery – Is There a Difference?

Background: Interest in the quality of life (QoL) of patients with morbid obesity continues to grow. Weight loss has been shown to improve QoL in obese persons undergoing a variety of treatments, but there is little data available comparing different surgical procedures and QoL questionnaires. Methods: In 133 patients, four different questionnaires where applied: the SF-12v2 (short form of SF-36), the BAROS (Bariatric Analysis and Reporting Outcome System), the GIQLI (Gastrointestinal Quality of Life Index) and the BQL (Bariatric Quality of Life Score). These patients underwent laparoscopic gastric banding (LAGB; n = 55), laparoscopic Roux-en-Y gastric bypass (RYGB; n = 49), biliopancreatic diversion with duodenal switch (BDP-DS; n = 23), or vertical banded gastric bypass (VBGB). All these procedures where performed in one bariatric center in Germany. Results: In all groups, QoL scores and excess weight loss (EWL) improved considerably, but EWL was clearly higher in BPD-DS and RYGB patients (62 and 60%) as compared to LAGB cases (47%). Similarly, standardized 1-year BQL scores were better for BPD-DS and RYGB (76 and 80%) than for LAGB (71%). Furthermore, weight changes over time seemed to reach a plateau phase in the LAGB patients, whereas BPD-DS led to continuing weight loss. Discussion: Although all procedures are effective, our data show important differences between the different procedures. Since weight loss after LAGB is smaller and less progressive, smaller improvements in QoL can be expected although the risk of complications is less. This should be borne in mind when selecting the type of surgery.

Lebensqualität nach bariatrischen Eingriffen – ein Überblick

Quality of Life after Bariatric Treatment – an Overview Quality of life has become more and more important in surgery. Especially in the field of bariatric surgery evaluation tools advanced a lot. This article is a review of literature concerning quality of life and its evaluation tools with regard on obesity and obesity surgery. This article reviews the so far published literature on obesity and obesity surgery with respect to assessment of quality of life (QoL) and the Qol evaluation tools used. Obesity significantly decreases the Qol of patients, and there is great evidence that the QoL of obese patients is improving after bariatric surgery. For evaluation of QoL the following questionnaires were predominantly used: SF-36, GIQoL index, and BAROS.

Der Magenballon – eine retrospektive Kohortenanalyse mit 634 Patienten

Hintergrund: Der temporÄre Einsatz eines Magenballons zur Behandlung der Adipositas Grad1 und 2 nimmt weltweit zu; bei der Adipositas Grad 3 wird der Magenballon als adjuvantes Hilfsmittel zur prÄoperativen Gewichtsreduktion implantiert. Ziel dieser retrospektiven Kohorten analyse ist, die Wirksamkeit des Magenballons auf Gewichtsreduzierung und das Risikoprofil der Methode zu evaluieren. Methoden: Retrospektive Kohortenanalysen aus 4 Adipositas-Zentren, in denen der Magenballon seit 2001 regelmÄßig implantiert wurde. Ergebnisse: Von Februar2001 bis April 2008 wurde bei 634 Patienten ein Magenballon implantiert (BIBTM Intragastric Balloon System; Allergan Medical, Irvine, CA, USA). Die Geschlechterverteilung war 31,5% MÄnnerzu 68,5% Frauen; das Durchschnittsalter betrug 41,5 Jahre. Das durchschnittliche Ausgangsgewicht lag bei 126 kg. Der initiale BMI bei Implantation des Magenballons war 42,5 kg/m2. Die Implantation der Prothese war in allen FÄllen unkompliziert. Der durchschnittliche Gewichtsverlust lag bei 20,75 kg bzw. 7,05 BMI-Punkten.BACKGROUND The temporary use of a gastric balloon for the treatment of obesity grade 1 and 2 is increasing worldwide,whereas in grade 3 obesity, it is implanted as a tool for preoperative adjuvant weight loss. The aim of this retrospective cohort analysis is to evaluate the effectiveness of weight reduction and to describe the risk profile of the method. METHODS Retrospective cohort analysis of 4 obesity centers where gastric balloons had been regularly implanted since 2001. RESULTS Between February 2001 and April 2008, the gastric balloon(BIB Intragastric Balloon System; Allergan Medical,Irvine, CA, USA) was implanted in 634 patients. The gender ratio was 31.5% males to 68.5% females; the average age was 41.5 years. The average initial weight was 126 kg. The initial BMI at implantation of the gastric balloon was 42.5 kg/m2.The implantation of the prosthesis was uncomplicated in all cases. Average weight loss was 20.75 kg or 7.05 BMI points, respectively.

The 6th Frankfurt Meeting for Surgery of Obesity and Metabolic Disorders

12 years after the first scientific meeting to the topic ‘Surgery for Morbid Obesity’ in Germany, the 5th Frankfurt meeting in 2008 extended the main topics surgery and obesity into ‘Obesity and Metabolic Surgery’. Between 2002 and 2009, the meeting took place in the old town hall of Frankfurt, called Romer since centuries, which contributed to the special and familiar atmosphere. All lectures were presented in the plenary session room of the Parliament of Frankfurt am Main, but with the increasing interest in the field, the town hall became too small. Therefore, the 6th Frankfurt meeting changed the location from the town hall to the congress palace in 2010. 540 experts in the field, more than initially expected, came and took part in the different sessions and workshops. The congress offered a comprehensive overview of the latest advances, breakthroughs and novelties in the minimally invasive treatment of this fatal modern age epidemic. At the one end of the malnutrition scale, obesity is one of today’s most blatantly visible – yet most neglected – public health problems. Paradoxically coexisting with malnutrition, an escalating global epidemic of overweight and obesity – ‘globesity’ – spread over many parts of the world. If no immediate action takes place, millions will suffer from an considerable number of serious health disorders. Obesity is a complex condition with serious social and psychological dimensions that affects virtually all age and socioeconomic groups and threatens to overwhelm both developed and developing countries. In 1995 there were an estimated 200 million obese adults worldwide and another 18 million children under the age of 5 that were classified as overweight. As of 2000 the number of obese adults has increased to over 300 million. Contrary to common expectations, the obesity epidemic is not restricted to industrialized societies. It is estimated that in developing countries over 115 million people suffer from obesity-related problems. As commonly known, obesity surgery is the only effective strategy to treat severely obese patients. Obesity treatment should be individually tailored, and all crucial factors, such as sex, the degree of obesity, individual health risks as well as psychobehavioral and metabolic characteristics, should be taken into account. The spectrum of the procedures in obesity surgery is subject to continuous change and improvement. During the last 2 years, laparoscopic sleeve gastrectomy (LSG) increasingly has attracted the attention of surgeons and patients. LSG is an effective first line operation to achieve definitive weight loss in suitable patients and is also applied as revision treatment if other surgical interventions did not succeed. Its advantages are that i) it is not as technically difficult as the laparoscopic biliopancreatic diversion duodenal switch, ii) it can lead to very good weight loss results in the medium term and iii) it can help to reverse co-morbidities, thereby further improving patient’s health as well as lessening the risk if further surgical weight loss interventions should be necessary. LSG also has a strong short-term effect on the metabolic syndrome but, when compared with gastric bypass surgery, weight regain results in an earlier recurrence of the diabetes situation. Because LSG is a restrictive rather than a malabsorptive procedure, nutritional concerns are much less than with bypass surgeries. However, the quality control study in Germany showed that this type of surgery is accompanied by more major complications and a higher mortality than the gastric bypass intervention in experienced hands. The Achilles heel of LSG is still the staple line leak in the angle of His. Therefore, also another surgical weight loss intervention, namely gastroplication, attracts more and more attention. With this procedure the risk of leaks is nonexisting, and the procedure can be performed endoscopically. The mechanism of restriction seems to be comparable with that of sleeve gastrectomy.

Lebensqualität nach Adipositas-Chirurgie: Ergebnisse nach verschiedenen Operationsverfahren – erste Ergebnisse einer prospektiven Längsschnittstudie

Interest in the quality of life (QoL) of patients with morbid obesity continues to grow. Weight loss has been shown to improve quality of life in obese persons undergoing a variety of treatments, but there is little data available on the comparative value of different surgical procedures and QoL questionnaires. Materials and Methods: In the Center for Obesity Surgery (Zentrum fdr Adipositaschirurgie), a QoL survey was done in all patients undergoing bariatric surgery between 2002 and 2004, using two different questionnaires: the BQL and the SF-12. The following surgical procedures were performed: gastric banding, Roux-en-Y gastric bypass and biliopancreatic diversion (BPD) according to Scopinaro. QoL questionnaires were filled in preoperatively 6 and 12 months postoperatively. Results: In 114 of 403 patients data were available for all times mentioned above and could be further analyzed. The mean age was 38.24 years, and the preoperative BMI was 45.41. 88.6% were female. A significant decrease of the BMI as well as an increase of QoL were found in all groups. Remarkable differences in the course of the BMI and the QoL were found when comparing the first 6 months with 6th to 12th postoperative month. Conclusion: Although all procedures are effective, our data showimportant differences between the different procedures. Therefore evaluation of QoL should be done in all hospitals performing bariatric surgery.