Faculty Bibliography

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/m2 (+/-7) dropping to 37.9 kg/m2 (+/-8.3) at 12 months and 36.8 kg/m2 (+/-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.

BACKGROUND AND OBJECTIVES: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a complex procedure performed in a patient population with significant medical comorbidities. Evaluation and modification of surgical techniques can minimize the complications associated with the lengthy learning curve for this procedure. The purpose of this study was to evaluate a single surgeon's decade-long experience with LRYGB, to determine whether complications decreased with experience and surgical modifications improved perioperative outcomes. METHODS: A retrospective review of all procedures performed by a fellowship-trained surgeon (MK) from December 1, 2000, to October 31, 2013, identified patients who underwent LRYGB. We evaluated perioperative outcomes in 1117 patients and examined the impact of modification of surgical techniques on complications. The patients were divided into 4 groups: cases 1-100 (group 1), cases 101-400 (group 2), cases 401-700 (group 3), and cases 701-1117 (group 4). RESULTS: Operating time decreased significantly after the initial 100 cases, from 179.1 minutes for group 1 to 122.1 minutes for group 4. With experience, early complication rates improved from 25.0% to 5.0%, but the rates of early reoperation increased from 1.0% to 2.2% over the 4 case groups. Late complication and reoperation rates increased from 4.0% to 10.5%. However, rates of bleeding, early stricture, internal hernia, and wound infection all decreased after the modification of surgical techniques. CONCLUSIONS: Operating time and early complication rates decreased with operative experience, but late complication and early and late reoperation rates increased. However, after modifications of surgical technique, common complications of LRYGB decreased to rates lower than those reported in several gastric bypass case series in the literature. The findings in this study will be helpful to fellow bariatric surgeons who are refining their strategies for reducing morbidity related to LRGYB.

BACKGROUND: Sleeve gastrectomy (SG) is being performed as a conversion after adjustable gastric banding (AGB), often in a single stage. However, some argue that it should be performed in 2 stages to improve safety. Few studies compare complications between 1-stage and 2-stage procedures. Our aim is to compare the 30-day complication rates among these two groups. METHODS: We retrospectively reviewed patients converted from AGB to SG between 8/2008 and 10/2013 and compared patients undergoing 1-stage and 2-stage techniques. Primary outcome was overall 30-day adverse event rate (postoperative complication, readmission, or reoperation). Secondary outcomes included operating room (OR) time, length of stay (LOS), leak, infection, and bleeding rates, as well as mortality. RESULTS: A total of 83 patients underwent SG after band removal; three were excluded due to short follow-up, leaving 60 1-stage and 20 2-stage. Mean time from band removal to SG for 2-stage was 438 days. Demographics, intraoperative technique (bougie size, staple reinforcement, oversewing staple line, and leak test), and mean follow-up were not statistically different. Mean OR time (132.1 min 1-stage vs. 127.8 min 2-stage, p = 0.702) and LOS (3.1 vs. 2.4 days, p = 0.676) were similar. Overall 30-day adverse event rate was 12 % for 1-stage versus 15 % for 2-stage procedures (p = 0.705). Differences in 30-day readmission (8 vs. 5 %) and reoperation (5 vs. 0 %) were not statistically significant (p = 0.999 and 0.569, respectively). Leak (3 vs. 0 %, p = 0.999), abscess (2 vs. 5 %, p = 0.440), and bleeding rates (2 vs. 0 %, p = 0.999) were not different. There were no deaths. CONCLUSIONS: SG performed as a conversion after AGB is safe and feasible. Our findings indicate no statistical difference in 30-day outcomes when performed in 1 or 2 stages. Future studies with larger sample sizes are necessary to further investigate these differences.

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/m. At reoperation, weight was 89.18 +/- 20.51 kg, BMI was 32.25 +/- 6.50 kg/m and, %EWL was 54.13 +/- 21.80%. Twelve months postrevision, weight was 92.24 +/- 20.22 kg, BMI was 33.32 +/- 6.41 kg/m, and %EWL was 48.81 +/- 22.71%. Weight was 92.42 +/- 19.91 kg, BMI was 33.53 +/- 6.25 kg/m, 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.

Aims: Laparoscopic adjustable gastric banding (LAGB), sleeve gastrectomy (LSG) and roux-en-y gastric bypass (LRYGB) are safe and effective bariatric procedures. Weight loss failure occurs and revision procedures are often performed. Our aim is to review our experience converting LAGB failures into LRYGB and LSG. Methods: This is a retrospective review of 121 patients (2008-2012) who underwent bariatric revision procedures after weight loss failure or intolerance to LAGB. We compared patients revised into LRYGB and LSG. Parameters reviewed include 30-day readmissions, reoperations, operating time, length of stay (LOS), and percent excess weight loss (%EWL) from primary and secondary procedures. Four of 91 LAGB to LRYGB and 3 of 30 LAGB to LSG underwent open procedures. Results: Data on 121 revised patients was assessed 91 LAGB to LRYGB (Group 1) and 30 LAGB to LSG (Group 2). Group 1's average OR time was 168.29 min; Group 2's was 146.24 min (p = .031). Group 1's mean LOS was 4.53 days while Group 2's was 3.9 days (p = 0.628). Group 1 patients experienced 12 of 91 (13.19%) bypass related reoperations; Group 2 patients experienced 1 of 30 (3.33%) sleeve related reoperations (p = .133). Group 1 patients had 10 30-day readmissions (10.99%); Group 2 had 2 30-day readmissions (6.67%) (p = .496). Regarding the first year after conversion, %EWL from the revision was reviewed. The %EWL for the bypass versus sleeve group was 24.45 vs. 22.50 at 3 months, 44.22 vs 24.77 at 6 months, and 47.16 vs 34.12 at 12 months (p values respectively: 0.406, 0.002, 0.179). Of note, %EWL from pre-LAGB was: (bypass vs sleeve) 36.96 vs. 22.5 at 3 months, 49.07 vs 40.27 at 6 months, and 54.78 vs. 34.12 at a year. Conclusions: For patients exhibiting weight loss failure or intolerance to LAGB, both LSG and LRYGB are safe options with comparable length of stay, readmissions, and reoperations. Operative time is significantly shorter with conversion to LSG. Additional weight loss from the revision procedure is moderate in all ca!

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.

BACKGROUND: It has been demonstrated that hiatal hernia repair (HHR) during laparoscopic adjustable gastric banding (LAGB) decreases the rate of reoperation. However, the technical aspects (location and number of sutures) are not standardized. It is unknown whether such technical details are associated with differing rates of reoperation for band-related problems. METHODS: A retrospective analysis was performed from a single institution, including 2,301 patients undergoing LAGB with HHR from July 1, 2007 to December 31, 2011. Independent variables were number and location of sutures. Data collected included demographics, operating room (OR) time, length of stay (LOS), follow-up time, postoperative BMI/%EWL, and rates of readmission/reoperation. Statistical analyses included ANOVA and Chi squared tests. Kaplan-Meier, log-rank, and Cox regression tests were used for follow-up data and reoperation rates, in order to account for differential length of follow-up and confounding variables. RESULTS: There was no difference in length of follow-up among all groups. The majority of patients had one suture (range 1-6; 55 %). Patients with fewer sutures had shorter OR time (1 suture 45 min vs. 4+ sutures 56 min, p < 0.0001). LOS, 30-day readmission, band-related reoperation, and postop BMI/%EWL were not statistically significant. Anterior suture placement (vs. posterior vs. both) was most common (61 %). OR time was shorter in those with anterior suture (41 min vs. posterior 56 min vs. both 59 min, p < 0.0001). Patients with posterior suture had a longer LOS (84 % 1 day vs. anterior 74 % 1 day vs. both 74 % 1 day, p < 0.0001). There was no difference in 30-day readmission, band-related reoperation, and postoperative BMI/%EWL. CONCLUSIONS: Patients with fewer or anterior sutures have shorter OR times. However, 30-day readmission, band-related reoperation, and postoperative weight loss were unaffected by number or location of suture. The technical aspects of HHR did not appear to be associated with readmission or reoperation, and therefore a standardized approach may not be necessary.