Faculty Bibliography

BACKGROUND: Obesity in the adolescent population has reached epidemic proportions. Although diet and behavior modification can help a minority of teenagers, most of these patients go on to become obese adults. Recently, surgical intervention for morbid obesity has gained increasing support. To date, this has only included gastric bypass procedures. However, this procedure carries at least a 1% mortality rate even in the hands of the most experienced surgeons. Therefore, our center has been using laparoscopic adjustable gastric banding (LAGB) to treat adolescents with morbid obesity. This analysis is a report of our short-term results in our first 53 patients. METHODS: All adolescents aged 13 to 17 years who had undergone LAGB at our institution and had been entered into our prospectively collected database since 2001 were reviewed. Data collected preoperatively included age, sex, race, and body mass index (BMI). Postoperatively recorded data included length of stay, operative morbidity, need for reoperation, as well as percentage of excess weight loss (%EWL) and BMI at 3-month intervals. RESULTS: Fifty-three teenagers aged 13 to 17 years (mean, 15.9 years) underwent LAGB at our institution since September 2001. Of these, 41 were female and 12 were male. The mean preoperative weight was 297 +/- 53 lb and the mean initial BMI was 47.6 +/- 6.7 kg/m2. The %EWL was 37.5 +/- 17.0 at 6 months, 62.7 +/- 27.6 at 1 year, and 48.5 +/- 15.6 at 18 months of follow-up. There were no intraoperative complications. Two patients had band slips that required laparoscopic repositioning, and 2 patients developed a symptomatic hiatal hernia that required laparoscopic repair. All of these procedures were performed as outpatient procedures. A fifth patient developed a wound infection requiring incision and drainage. Other complications included mild hair loss in 5 patients, iron deficiency in 4 patients, nephrolithiasis and cholelithiasis in 1 patient, and gastroesophageal reflux in 1 patient. CONCLUSIONS: Laparoscopic adjustable gastric banding is not only a safe operation for morbidly obese pediatric patients, but also represents an effective treatment strategy with a %EWL of approximately 50% at both 1 year and 18 months of follow-up. Because of the minimal morbidity and complete absence of mortality of the LAGB, it is the optimal surgical option for pediatric patients with morbid obesity

BACKGROUND: Parenteral administration of opioids and NSAIDs has been the mainstay for postoperative pain control in patients undergoing laparoscopic adjustable gastric banding (LAGB). Both classes of drugs, however, are associated with serious adverse effects. An addition of complimentary analgesic techniques may decrease requirement for traditional analgesics, thus reducing the incidence of side-effects. We designed the study to evaluate the effectiveness of Lavender aromatherapy in reducing opioid requirements after LAGB. METHODS: A prospective randomized placebo controlled study was carried out on 54 patients undergoing LAGB. Upon arrival to the post-anesthesia care unit (PACU), patients in the study group were treated with lavender oil, which was applied to the oxygen face mask; the control group patients received nonscented baby oil. Postoperative pain was treated with morphine. Numerical rating scores (0-10) were used to measure the level of pain at 5, 30, and 60 min. Sedation was evaluated using the Observer Assessment of Alertness/Sedation scale (0-5). Data analyzed included the amount of opioids, NRS, OAA/S, PACU discharge time, as well as the incidence of side-effects. RESULTS: The two groups were comparable with regard to patient characteristics, intraoperative drug use, and surgical time. Significantly more patients in the Placebo group (PL) required analgesics for postoperative pain (22/27, 82%) than patients in the Lavender group (LAV) (12/26, 46%) (P = .007). Moreover, the LAV patients required significantly less morphine postoperatively than PL patients: 2.38 mg vs 4.26 mg, respectively (P = .04). There were no differences in the requirements for post-operative antiemetics, antihypertensives, or PACU discharge time. CONCLUSIONS: Our results suggest that lavender aromatherapy can be used to reduce the demand for opioids in the immediate postoperative period. Further studies are required to assess the effect of this therapy on clinically meaningful outcomes, such as the incidence of respiratory complications, delayed gastric emptying, length of hospital stay, or whether this therapy is applicable to other operations

BACKGROUND: Bariatric operation is the most effective treatment for diabetes mellitus in the morbidly obese. The purpose of this study is to compare the rate of resolution of diabetes mellitus after three common laparoscopic bariatric procedures: laparoscopic adjustable gastric banding (LAGB), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion with or without duodenal switch (BPD/DS). STUDY DESIGN: All data were prospectively collected and entered into an electronic registry. Characteristics evaluated for this study included preoperative age, body mass index, duration of diabetes, race, gender, operative time, length of stay, percent excess weight loss, oral hypoglycemic requirements, and insulin requirements. RESULTS: A total of 282 bariatric patients with diabetes mellitus were analyzed (218 LAGB, 53 RYGB, and 11 BPD/DS). Preoperative age (46 to 50 years), body mass index (46 to 50; calculated as kg/m(2)), race and gender breakdown, and baseline oral hypoglycemic (82% to 87%) and insulin requirements (18% to 28%) were comparable among the three groups (p = NS). Percent excess weight loss at 1, 2, and 3 years was: 43%, 50%, and 45% for LAGB; 66%, 68%, and 66% for RYGB; and 68%, 77%, and 82% for BPD/DS (p < 0.01 LAGB versus RYGB and LAGB versus BPD/DS at all time intervals). At 1 and 2 years, the proportion of patients requiring oral hypoglycemics postoperatively was 39% and 34% for LAGB; 22% and 13% for RYGB; and 11% and 13% for BPD/DS (p = NS). At 1 and 2 years, the proportion of patients requiring insulin postoperatively was 14% and 18% for LAGB; 7% and 13% for RYGB; and 11% and 13% for BPD/DS (p = NS). CONCLUSIONS: Despite the disparity in percent excess weight loss between LAGB, RYGB, and BPD/DS, the rate of resolution of diabetes mellitus is equivalent

BACKGROUND: Several surgical treatment options for morbid obesity exist. Currently, there are no studies that objectively compare complication rates after laparoscopic bariatric operations performed at a single institution. We objectively classify and compare complications resulting from laparoscopic adjustable gastric banding (LABG), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion (BPD) with duodenal switch (DS). STUDY DESIGN: A retrospective review of a prospective database of all patients undergoing laparoscopic bariatric operation was performed. Complications were categorized according to severity score using a well-described classification system and compared between procedures. RESULTS: From September 2000 to July 2003, 780 laparoscopic bariatric operations were performed: 480 LAGB, 235 RYGB, and 65 BPD+/-DS. There was one late death. Total complication rates were: 9% for LAGB, 23% for RYGB, and 25% for BPD+/-DS. Complications resulting in organ resection, irreversible deficits, and death (grades III and IV) occurred at rates of 0.2% for LAGB, 2% for RYGB, and 5% for BPD+/-DS. LAGB group had a statistically significant lower overall complication rate, both by incidence and severity, as compared with other groups (p < 0.001). After controlling for differences of admission body mass index, gender, and race, the LAGB group had an almost three and a half times lower likelihood of a complication compared with the RYGB group (odds ratio, 3.4; 95% CI, 2.2-5.3, p < 0.001) and had an over three and a half times lower likelihood of a complication compared with the BPD with DS group (odds ratio, 3.6; 95% CI, 1.8-7.1, p < 0.001). There was no statistically significant difference between complication rates of RYGB and BPD+/-DS. CONCLUSIONS: Bariatric operation complication rates range from 9% to 25%; very few complications are serious. Laparoscopic adjustable gastric banding is the safest operation in terms of complication rate and severity when compared with laparoscopic Roux-en-Y gastric bypass or laparoscopic malabsorptive operations