Faculty Bibliography

Background: The purpose of this study was to objectively assess the resolution of obesity-related comorbidities (ORC) after bariatric surgery and to compare the status and resolution of comorbidities following laparoscopic adjustable gastric banding (LAGB), roux-en-Y gastric bypass (RYGB), and sleeve gastrectomy (LSG). Methods: Data was collected from an IRB-approved electronic registry, including patient demographics, weight, BMI, and ORC status. Using the registry, ten ORCs were scored, pre-op and post-op, from 0-5 according to severity using the Assessment of Obesity-Related Comorbidities (AORC) Scale, the basis for the Bariatric Outcomes Longitudinal Database. The ten ORCs were: osteoarthritis (OA), diabetes, hypertension (HTN), obstructive sleep apnea, hyperlipidemia (HLD), gastroesophageal reflux disease, depression, urinary stress incontinence, hernia, and lower extremity edema (LEE). Resolution of disease was defined as having AORC>0 pre-surgery and AORC=0 post-surgery. Change in ORC status was calculated with the following equation: (pre-op AORC score) - (post-op AORC score). Paired t-tests were utilized to determine whether comorbidity change was significant following bariatric surgery. Fisher's exact tests were used to determine if there was a significant difference in ORC resolution between procedures. Results: 264 patients with ORC underwent bariatric surgery between January 2008 and March 2010 at an urban safety-net hospital. Average pre-op age was 42.5, and average pre-op BMI was 44.2. At mean patient follow-up of 17.2 months, the %EWL of RYGB, LSG and LAGB was 43.6%, 37.4% EWL, and 23.3% EWL, respectively (p < .0001). Resolution of 4 comorbidities (OA, HTN, HLD, and LEE) was found to be significantly different between surgery types (p<0.05): The percentage of patients with OA resolution was 71% for RYGB, 63% for LSG, and 51% for LAGB. HTN resolution was 57% for RYGB, 23% for LAGB, and 29% for LSG. HLD resolution was 71% for LSG, 67% for RYGB, and 34% for LAGB. LEE resolution was 100% for LSG (n=6), 94% for RYGB, and 68% for LAGB. RYGB produced an overall mean ORC resolution of 66%, vs 60% and 44% produced by LSG and LAGB, respectively. All bariatric surgery procedures had statistically significant AORC score change for all 10 documented comorbidities (p < .0001). The overall mean change in AORC score for all comorbidities, from pre-op to post-op, was 1.7 for RYGB patients, 1.4 for LSG patients, and 1.2 for LAGB patients. There was no significant association between initial BMI and change in AORC score. The pre-op AORC scores were not significantly different between surgery types. Conclusions: RYGB had the greatest ORC resolution for patients with OA and HTN, as well as the greatest mean ORC status improvement overall. LSG produced the greatest significant ORC resolution for patients with HLD and LEE. RYGB, LSG, and LAGB had statistically significant ORC status improvement for all 10 documented comorbidities

Introduction: The purpose of this study is to correlate gastric emptying after laparoscopic sleeve gastrectomy (LSG) and calculated sleeve size (based on radiographic characteristics and pathologic resection) with post-op weight loss. Methods: Data was collected from an IRB-approved electronic registry, including patient demographics, weight, and body mass index (BMI). All sleeves were done with 40Fr Bougie, starting 5-7 cm proximal to pylorus. Post-op esophagrams were evaluated by 2 attending radiologists who specialized in body-imaging for 1) post-op radiographic sleeve diameter near top of sleeve, mid-sleeve and in antrum and 2) antrum-to-duodenum transit time. Sleeve volume was calculated utilizing the formula for cylinder volume r2h, where r=radius of mid-sleeve and h=height of the sleeve from gastroesophageal junction to distal antrum. Resected gastric volume was calculated utilizing radius and length of resected specimen (based on path report.) Excess weight loss (%EWL) was calculated based on ideal body weight. Pearson's correlation coefficient was used to evaluate the association between: transit time and weight loss, sleeve volume and weight loss, and transit time and sleeve diameter. Results: 62 patients underwent LSG (21% concurrent hiatal hernia repair) between Jan 2009 and Jan 2011 at an urban safety-net hospital. The population was 84% female, average pre-op age and BMI was 42 years and 47.0 kg/m², respectively. The transit time (available in 60 patients) ranged from 0-88 seconds (mean=21.3, SD= 19.8). 99% of the patients demonstrated gastric emptying under 60 seconds. Mean radiographic diameter of mid-sleeve was 4.0 cm and mean radiographic height was 26.4 cm. Based on these dimensions, mean calculated sleeve volume (based on cylindrical volume) was 115 cm3 (+/-81.0). Mean resected gastric volume (based on pathology specimen) was 658 cm3 (+/-945). Mean %EWL at 3, 6, and 12 months was 23.8% (+/-9.8), 37.9% (+/-11.8) and 52.2% (+/-10.8). There was no correlation found between transit time and %EWL at 3, 6 or 12 months. When dichotomizing the data between those with transit time <30 seconds vs. >30 seconds, there was still no significant correlation. There was also no correlation found between calculated sleeve volume or resected gastric volume and %EWL at 3, 6 or 12 months. However, shorter transit times were correlated with smaller mid-sleeve diameter (r=0.295, p-value=0.022) and smaller antrum diameter (r=0.255, p-value=0.049) but were not significantly correlated with upper sleeve diameter (r=0.120, p-value=0.360). Conclusion: We found no correlation between transit time after sleeve gastrectomy and weight loss, between sleeve volume and weight loss, and between resected gastric volume and weight loss. However, shorter transit time was correlated with smaller mid-sleeve and antrum diameter; the clinical significance of this remains to be determined

Laparoscopic sleeve gastrectomy (LSG) techniques vary significantly, including bougie size (32-60Fr), distance from pylorus (2-8 cm), antral preservation, proximity to GE junction, staple height/oversewing, and concurrent hiatal hernia repair. The literature is controversial regarding bougie size and weight loss after LSG, however there is certainly a trend towards the use of more narrow bougies (32Fr) with increasing surgeon experience. We have previously published a study comparing weight loss after LSG between 40Fr and 60Fr bougie and seeing no significant weight loss difference at 1 year; however the 60Fr bougie group was mainly firststage duodenal switch patients who were primarily superobese (mean BMI 63.1 at baseline). If one calculates the volume of the sleeve using the formula for cylinder (r2h) where h=25 cm (length of sleeve), the calculated volume for 32Fr bougie is 20cc, for 40Fr bougie is 32cc and 60Fr bougie is 71cc. At our institution, we have found no correlation between calculated sleeve volume (radiographically) and weight loss up to 1 year postoperatively. We did find a correlation between smaller diameter at midsleeve and more rapid emptying of liquid contrast postoperatively, however the accelerated emptying did not correlate with improved weight loss. What is the downside of using a more narrow bougie? There is conflicting literature regarding the complication rates and bougie size for LSG. There is concern that the tighter the sleeve, the higher the risk of a leak, especially near the GE junction. There are also reports of higher reflux rates with tighter bougies. Other large studies (e.g. Spanish Registry Data) have found no correlation between bougie size and complication rate. It is difficult to compare outcomes based on bougie size due to the variability of other intraoperative factors, including how closely the stapler is applied along the bougie, the amount of posterior fundus mobilized, the distance from the pylorus where the LSG begins, the amount of stretch applied laterally on the fundus, the presence of gastritis that affects thickness and distensibility of the stomach, and the use of buttressing material. These factors combined with the accelerated gastric emptying seen after LSG (suggesting that LSG may not be solely a restrictive procedure) make evidence-based comparisons difficult to perform. Larger studies with standardized techniques are needed to determine optimal bougie size

BACKGROUND: Evidence of the positive effects of gastric banding on patients with diabetes has continued to increase. The long-term follow-up of such patients, however, has been limited. The purpose of the present study was to provide the long-term outcomes of patients with diabetes undergoing laparoscopic adjustable gastric banding at our institution. METHODS: From January 2002 through June 2004, 102 patients with type 2 diabetes mellitus underwent laparoscopic adjustable gastric banding. The study parameters included preoperative age, gender, race, body mass index, duration of diabetes before surgery, fasting glucose level, hemoglobin A1c (HbA1c), and medications used. Preoperative data from all patients were collected prospectively and entered into an institutional review board-approved database. Beginning in 2008, efforts were made to collect the 5-year follow-up data. RESULTS: Of the 102 patients, 7 were excluded because they had not reached the 5-year follow-up point (2 patients had had the band removed early and 5 patients had died; 2 of cancer and 3 of unknown causes), leaving 95 patients for the present study. The mean preoperative age was 49.3 years (range 21.3-68.4). The mean preoperative body mass index was 46.3 kg/m(2) (range 35.1-71.9) and had decreased to 35.0 kg/m(2) (range 21.1-53.7) by 5 years of follow-up, yielding a mean percentage of excess weight loss of 48.3%. The mean duration of the diabetes diagnosis before surgery was 6.5 years. Of 94 patients, 83 (88.3%) were taking medications preoperatively, with 14.9% overall taking insulin. At 5 years postoperatively, 33 (46.5%) of 71 patients were taking medications, with 8.5% taking insulin. The mean fasting preoperative glucose level was 146.0 mg/dL. The glucose level had decreased to 118.5 mg/dL at 5 years postoperatively (P = .004). The mean HbA1c level was 7.53 preoperatively in 72 patients and was 6.58 at 5 years postoperatively in 64 patients (P <.001). Overall, diabetes had resolved (no medication requirement, with HbA1c <6 and/or glucose <100 mg/dL) in 23 (39.7%) of 58 patients and had improved (use of fewer medications and/or fasting glucose levels of 100-125 mg/dL) in 41 (71.9%) of 57 patients. The combined improvement/remission rate was 80% (64 of 80 patients). CONCLUSION: Our data have demonstrated that laparoscopic adjustable gastric banding results in a substantial sustained positive effect on diabetes in morbidly obese patients, with a significant reduction in HbA1c and an 80% overall rate of improvement/remission

OBJECTIVES: The goal of this study was to define the frequency of stent gaps by 64-detector computed tomographic angiography (CTA) and their relation to in-stent restenosis (ISR), stent fracture (SF), and overlap failure (OF). BACKGROUND: SF defined by catheter angiography or intravascular ultrasound has been implicated in ISR. METHODS: A total of 292 consecutive patients, with 613 stents, who underwent CTA were evaluated for stent gaps associated with decreased Hounsfield units. Correlations with catheter coronary angiography (CCA) were available in 143 patients with 384 stents. RESULTS: Stent gaps were noted in 16.9% by CTA and 1.0% by CCA. ISR by CCA was noted in 46.1% of the stent gaps (p < 0.001) as determined by CCA, and stent gaps by CTA accounted for 27.8% of the total ISR (p < 0.001). In univariate analysis, stent diameter > or =3 mm was the only CCA characteristic significantly associated with stent gaps (p = 0.002), but was not a significant predictor by multivariate analysis. Bifurcation stents, underlying calcification, stent type, location, post-dilation, and overlapping stents were not observed to be predisposing factors. Excessive tortuosity and lack of conformability were not associated with stent gaps; however, their frequency was insufficient to permit meaningful analysis. CONCLUSIONS: Stent gap by CTA: 1) is associated with 28% of ISR, and ISR is found in 46% of stent gaps; 2) is associated with > or =3-mm stents by univariate (p = 0.002) but not by multivariate analysis; 3) is infrequently noted on catheter angiography; and 4) most likely represents SF in the setting of a single stent, and may represent SF or OF in overlapping stents.

BACKGROUND: Many mildly to moderately obese individuals with a body mass index (BMI) lower than 35 kg/m(2) have serious diseases related to their obesity. Nonsurgical therapy is ineffective in the long term, yet surgery has never been made widely available to this population. METHODS: Between 2002 and 2007, 53 patients with a BMI lower than 35 kg/m(2) underwent laparoscopic adjustable gastric banding at our institution. Data on all these patients were collected prospectively and entered into an institutional review board-approved electronic registry. The study parameters included preoperative age, gender, BMI, presence of comorbidities, percentage of excess weight loss (%EWL), and resolution of comorbidities. RESULTS: The mean preoperative age of the patients was 46.9 years (range, 16-68 years), and the mean preoperative BMI was 33.1 kg/m(2) (range, 28.2-35.0 kg/m(2)). Of the 53 patients, 49 (92%) had at least one obesity-related comorbidity. The mean BMI decreased to 28.1 +/- 2.4 kg/m(2), 25.8 +/- 2.9 kg/m(2), and 25.8 +/- 3.1 kg/m(2) and mean %EWL was 48.3 +/- 17.6, 69.9 +/- 28.0, and 69.7 +/- 31.7 at 0.5, 1, and 2 years, respectively. Substantial improvement occurred for the following comorbidities evaluated: hypertension, depression, diabetes, asthma, hypertriglyceridemia, obstructive sleep apnea, hypercholesterolemia, and osteoarthritis. There was one slip, two cases of band obstruction (from food), two cases of esophagitis, and two port leaks, but no mortality. CONCLUSION: The authors are very encouraged by this series of low-BMI patients who underwent laparoscopic adjustable gastric banding. Their weight loss has been excellent, and their complications have been acceptable. Their comorbidities have partially or wholly resolved. With further study, it is reasonable to expect alteration of the weight guidelines for bariatric surgery to include patients with a BMI lower than 35 kg/m(2)

The epidemic of obesity in the United States is a major public health issue and more than a third of adults are now considered obese (body mass index > or = 30 kg/m(2)). Surgery for morbid obesity, bariatric surgery, is the most durable treatment for this disease and about 140,000 cases are performed annually. Laparoscopic sleeve gastrectomy (LSG) has been advocated as the first of a 2-stage procedure for the high-risk, super-obese patient. More recently, LSG has been studied as a single-stage procedure for weight loss in the morbidly obese. LSG has been shown in initial studies to produce excellent excess weight loss comparable with laparoscopic Roux-en-Y gastric bypass in many series with a very low incidence of major complications and death. We describe our technique for LSG

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has been increasingly offered to high-risk bariatric patients as the first-stage procedure before gastric bypass or biliopancreatic diversion or as the primary weight loss procedure. The bougie size has varied by surgeon during LSG. The aim of this study was to determine whether short-term weight loss correlates with the bougie size used during creation of the sleeve. METHODS: We retrospectively reviewed the data from all patients who had undergone LSG at our institution between 2003 and 2006. Revision LSG for failed bariatric procedures was excluded. The data analyzed included preoperative age, body mass index (BMI), bougie size, and percentage of excess weight loss (%EWL). RESULTS: A total of 135 patients underwent LSG during the 4-year period. Most of these patients (79%) underwent LSG as part of a 2-stage operation (either gastric bypass or duodenal switch within a mean of 11 months). The mean preoperative age and BMI was 43.5 years and 60.1 kg/m(2), respectively. The mean BMI and %EWL at 6 months was 47.1 kg/m(2) and 37.9%, respectively. The mean BMI and %EWL at 12 months was 44.3 kg/m(2) and 47.3%, respectively. When stratifying the %EWL by bougie size (40F versus 60F), we did not find a significant difference at 6 months (38.8% versus 40.6%, P = NS) or 12 months (51.9% versus 45.4%, P = NS). CONCLUSION: LSG results in significant weight loss in the short term. When stratifying outcomes by bougie size, our results suggested that a bougie size of 40F compared with 60F does not result in significantly greater weight loss in the short term. However, longer follow-up of the primary LSG group is required to determine whether a difference becomes evident over time.

BACKGROUND: This study reviews outcomes after laparoscopic adjustable gastric band (LAGB) placement in patients with weight loss failure after Roux-en-Y gastric bypass (RYGBP). METHODS: All data was prospectively collected and entered into an electronic registry. Characteristics evaluated for this study included pre-operative age and body mass index (BMI), gender, conversion rate, operative (OR) time, length of stay (LOS), percentage excess weight loss (EWL), and postoperative complications. RESULTS: 11 patients (seven females, four males) were referred to our program for weight loss failure after RYGBP (six open, five laparoscopic). Mean age and BMI pre-RYGBP were 39.5 years (24-58 years) and 53.2 kg/m(2) (41.2-71 kg/m(2)), respectively. Mean EWL after RYGBP was 38% (19-49%). All patients were referred to us for persistent morbid obesity due to weight loss failure or weight regain. The average time between RYGBP and LAGB was 5.5 years (1.8-20 years). Mean age and BMI pre-LAGB were 46.1 years (29-61 years) and 43.4 kg/m(2) (36-57 kg/m(2)), respectively. Vanguard (VG) bands were placed laparoscopically in most patients. There was one conversion to open. Mean OR time and LOS were 76 minutes and 29 hours, respectively. The 30-day complication rate was 0% and mortality was 0%. There were no band slips or erosions; however, one patient required reoperation for a flipped port. The average follow-up after LAGB was 13 months (2-32 months) with a mean BMI of 37.1 kg/m(2 )(22.7-54.5 kg/m(2)) and an overall mean EWL of 59% (7-96%). Patients undergoing LAGB after failed RYGBP lost an additional 20.8% EWL (6-58%). CONCLUSION: Our experience shows that LAGB is a safe and effective solution to failed RYGBP