Faculty Bibliography

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.

Aims: Laparoscopic adjustable gastric banding (LAGB) has gained popularity as a safe, reversible surgical treatment for morbid obesity. However, there are few studies and no consensus on revisional bariatric surgery for those patients in whom banding has failed. We analyzed results of conversion from LAGB to Roux-en-Y gastric bypass or biliopancreatic diversion in one high-volume center. Methods: A single-institution retrospective review was conducted on patients who had undergone conversion of LGB to a revisional bypass procedure during the time period January 2003 through November 2011. Data on patient demographics, surgical technique, pre- and post-operative complications, and weight loss (body mass index [BMI] and percent excess weight loss [%EWL]) were collected and analyzed. Results: We identified 76 patients at our institution who underwent conversion from LAGB to Roux-en-Y gastric bypass (RYGB; n = 62), biliopancreatic diversion (BPD; n = 12), or biliopancreatic diversion with duodenal switch (BPD/DS; n = 2). 69 of the 76 conversions (90.8%) were completed laparoscopically. 29/76 (38.2%) had required additional surgery prior to conversion for band-related complications including slippage, erosion, port migration, hiatal hernia, bowel obstruction, or leakage; all occurred at >;30 days. After conversion, the rate of complications requiring hospitalization was 27.6% (21/76); 14.5% (11/76) occurred at<30 days. There was one mortality. Mean time from band placement to conversion was 1439 +/- 661.4 days (range 245-3140). At time of conversion, mean BMI was 44.4 +/- 6.6 kg/ m², and mean %EWL was 12.21 +/- 20.7 (range 67-75). Following conversion, mean BMI and %EWL at 12 months, respectively, were 31.6 +/- 4.2 kg/m² and 55.2 +/- 24.7, at 24 months 33.6 +/- 5.6 kg/m² and 45.3 +/- 20.1, and at 36 months 33.0 +/- 7.5 kg/m² and 46.0 +/- 18.2. Conclusions: There is an increasing need for proven corrective solutions to failed LAGB. Our results show that con!

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is safe and effective. This less invasive option involving fewer incisions and umbilical approaches is coined as single-incision laparoscopic surgery (SILS). Over the last 3 years, we performed 46 % of our LAGBs as SILS with excellent results. METHODS: This is a retrospective review of 1,644 LAGBs performed between 2008 and 2010. A total of 756 were performed as SILS bands (46 %) and 888 as standard (non-SILS) (54 %). Data points compared include operative time, percent of excess weight loss at 1 and 2 years, complication, and re-operation rates. RESULTS: Groups were matched by age, initial BMI, and gender: 584 non-SILS and 710 SILS patients. The average operating time was 44.3 +/- 19.6 min for SILS and 51.1 +/- 19.4 min for non-SILS (p < 0.001). The 12-month percent excess weight loss (%EWL) for SILS was 45.0 +/- 19.1; it was 40.7 +/- 17.5 for non-SILS (p = 0.003). The 24 month %EWL for SILS was 54.4 +/- 16.3; it was 46.4 +/- 16.1 for non-SILS (p = 0.10). Complication rates were 5.6 % (40 of 710) for SILS and 4.5 % (26 of 584) for non-SILS (p = 0.34). The 30-day readmission/re-operation rates are 1 % (seven of 710) for SILS and 1.5 % (nine of 584) for non-SILS (p = 0.37). There was one death in the SILS group. CONCLUSIONS: We have been performing more SILS bands over time. Our operative times and weight loss figures show that it is an efficient and effective means of weight loss. Furthermore, the data also show that the SILS approach is safe and does not increase operative time. In conclusion, SILS laparoscopic adjustable gastric banding is a safe and effective means of attaining weight loss in selected patients.

Introduction: Postoperative (PONV) and postdischarge (PDNV) nausea and vomiting are common (60-70%) after bariatric surgery. Palonosetron (Pal), a novel 5-HT3 antagonist, is an effective antiemetic with a prolonged duration of action in the setting of PDNV. We hypothesized that combination therapy with Palonosetron (Pal) and dexamethasone (Dex) would improve treatment in comparison to Palonosetron alone in patients at high risk for PONV. Methods: In this study, patients undergoing bariatric laparoscopic surgery under general anesthesia, a subgroup of a larger Phase IV clinical trial of patients who had laparoscopic surgery, were randomized to 8 mg Dex + 0.075mg Pal or saline + 0.075mg Pal. Data was collected postoperatively at 2, 6, 24 and 72 hrs. A Functional Living Index-Emesis (QOL-FLIE) test was administered at 96 hrs. Results: We enrolled 76 ASA 1-2 patients with at least 3 PONV risk factors. Both randomization groups had a low incidence of vomiting in the PACU (Pal, 0.0%; Pal + Dex, 5.4%) as well as at 72 hours (0.0% both groups). Complete response (no vomiting, no rescue medication) was not different between treatment groups at any time intervals. Cumulative success rates over the entire 72 hrs were 60.4% (Pal alone) vs. 60.0% (Pal + Dex). Nausea scores (4 point ordinal scale) were not different between groups for any time intervals. Cumulative success scores for nausea (score = ""none""; 0-72 hrs) were 41.9% for the Pal group, and 55.2% for the Pal+ Dex group. The Pal + Dex group showed a trend toward greater satisfaction on the QOL-FLIE scores with the greatest differences in the ""nausea domain"". Discussion: The combination therapy (Pal + Dex) did not significantly reduce the incidence of PONV or PDNV when compared with Pal alone although a trend was observed indicating the possible increased efficacy of multi-drug therapy. There was no change in comparative efficacy over 72 hrs, possibly due to the low incidence of PDNV in both groups.

Laparoscopic adjustable gastric banding is one of several weight loss procedures in the bariatric surgeon's armamentarium to treat morbid obesity. Laparoscopic gastric banding has the lowest perioperative risk compared to laparoscopic gastric bypass, sleeve gastrectomy, and duodenal switch (Buchwald et al., JAMA 292:1724-1737, 2004). The adjustable gastric band results in approximately 50% excess weight loss at 5 years (O'Brien and Dixon,J Laparoendosc Adv Surg Tech A 13:265-270, 2003). In the long-term, reoperation rates can be high with the percentage of reoperations varying enormously in reported studies from 2% to 80% (Schouten et al., Surg Obes Relat Dis 7:99-109, 2011), although with changes in technique, reoperation rates after gastric banding have decreased (O'Brien et al., Obes Surg 15:820-826, 2005). Aftercare is critical to the success of the banded patient, in terms of adjusting the band as well as monitoring the patient's symptoms (Weichman et al., Surg Endosc 25:397-403, 2011). Several studies have shown that patients who are seen more than six to seven times in the first postoperative year have better weight loss.

Purpose: Bariatric surgery can achieve sustained weight loss compared to medical management. Among bariatric surgeries, laparoscopic adjustable gastric banding (LAGB) is less-invasive and potentially reversible. LAGB may decrease BMI through restriction of food intake, behavior changes, satiety and digestive hormone levels. The dramatic reduction of appetite observed with LAGB can be ameliorated if the band is underfilled. This effect has not been well evaluated in terms of patient behavior and hormonal changes. Our aim was to assess outcomes related to eating behavior, insulinotropic hormones, and weight change before and after temporary gastric band release. Methods: Adults >= 18 yeaars of age who previously underwent LAGB and achieved successful weight loss were enrolled. All patients underwent standardized evaluation including anthropometric measurements and completion of the Three-Factor Eating Questionnaire (TEFQ-R18) before and after a period of 14 days during which the band was completely loosened. At baseline and follow-up, blood was collected after an overnight fast and 1h after a standard high protein meal, and levels of insulinotropic hormones determined. Results: The mean age of the study cohort (9 women and 6 men) was 42 +/-14 years with mean pre-band adjustment BMI of 32.9 +/- 5.6 and mean waist circumference of 40 +/- 7 inches. All patients had >30% percent reduction in weight within 12-months of the LAGB and demonstrated a lower degree but continued weight loss in the 6-months before study enrollment. Compared to baseline values for the TEFQ-R18, within 2-weeks of loosening the band, cognitive restraint was reduced (11.2 +/- 3 vs. 10.4 +/- 4), while there was a significant increase in both disinhibition (6.4 +/- 3 vs. 9.4 +/- 3, p=0.004) and hunger scores (4.1 +/- 3 vs. 8.0 +/- 3, p=0.004). Compared to baseline, at follow-up insulin output in response to a meal showed a downward trend [Median (IQR) 1,110 (728-1,332) vs. 621 (375-1,325) pg/ml; p=0.21] while leptin was significantly elevated [10,400 (6,030-11,350) vs. 13,700 (10,500-43,900) pg/ml; p=0.001]. Consistent with these findings BMI significantly increased (32.9 +/- 5.6 vs. 34.5 +/- 5.6, p=0.001) along with waist size (40 +/- 7 vs 42 +/- 6, p=0.003). The amount of weight regained within two weeks, returned the cohort to the weight loss level noted at the 12-month post LAGB time point. Conclusion: LAGB adjustment continues to impact eating behavior, satiety hormones, and body weight beyond the initial 12-months following placement. Complete loosening of the LAGB can result in rapid changes in eating behavior, insulinotropic hormones, and significant changes in BMI. Careful adjustment of the band is necessary for continued maintenance of weight loss

Leaks after laparoscopic sleeve gastrectomy can be challenging to manage. Nonoperative management is preferred after the immediate postoperative period. No single treatment is effective in all cases. The best approach is to be persistent, to utilize a multidisciplinary team and to apply one or more endoscopic therapies, often in combination. We present a case of persistent leak after laparoscopic sleeve gastrectomy that highlights these issues

BACKGROUND: The need for revision after laparoscopic adjustable gastric band (LAGB) surgery has been reduced over the past 10 years with the introduction of the pars flaccida technique, delicate band tightening, and concurrent hiatal hernia repairs. However, band revision still occurs for as many as 5% of patients. Placement of a lesser-curvature gastrogastric suture distal to the band is one newer technique suggested to lower band slippage. To evaluate the worth of this technique, the authors have investigated two groups of patients in their practice: one group with the plication stitch and one group without it. METHODS: This retrospective review examined data for 1,365 LAGB patients collected prospectively by an institutional review board-approved database between July 2007 and May 2010. One surgeon did not perform the plication stitch (n = 776) and one did (n = 589). The surgical techniques were very similar. The majority of the patients had crural repair at the primary operation. Band revision rates were assessed. RESULTS: For 1,365 patients, LAGB was performed safely. The mean follow-up period was 22 months. The two groups were similar. The no-stitch group consisted of 776 patients (496 women, 64%) with a mean age of 42 years, a mean weight of 278 lb, and a mean body mass index (BMI) of 44.6 kg/m(2). The stitch group consisted of 589 patients (426 woman, 72%) with a mean age of 40 years, a mean weight of 278 lb, and a mean BMI of 44.8 kg/m(2). The no-stitch group had an estimated weight loss (EWL) of 44% at 12 months and 50% EWL at 2 years. The stitch group had 37% EWL at 12 months and 45% EWL at 2 years. Both groups had very low revision rates. The no-stitch group had 4 revisions in 776 patients (0.26%), and the stitch group had 9 revisions in 589 patients (1.5%). CONCLUSION: Adding gastrogastric plication sutures offers no benefit of reducing the rate of revision after LAGB surgery