High preoperative HbA1c does not affect early or late complication rates after bariatric surgery.

BACKGROUND: Preoperative HbA1c has been associated with an increased incidence of postoperative morbidity and mortality after abdominal and cardiovascular surgery. The literature on bariatric surgery is inconclusive and guidelines recommend postponement of surgery when HbA1c is above an arbitrary threshold (≥ 8.5%). In this study, we sought to understand the impact of preoperative HbA1c on early and late postoperative complications. METHODS: We performed a retrospective analysis of prospectively collected data on obese patients with diabetes who underwent laparoscopic bariatric surgery. Patients were categorized into three groups according to their preoperative HbA1c level: < 6.5% (group 1), 6.5-8.4% (group 2) and ≥ 8.5% (group 3). Primary outcomes were early and late postoperative complications (< and > 30 days, respectively) that were differentiated based on severity (major/minor). Secondary outcomes were length of stay (LOS), duration of surgery, and rate of readmission. RESULTS: In total, 6798 patients underwent laparoscopic bariatric surgery from 2006 to 2016, of which 1021 (15%) patients had Type 2 Diabetes (T2D). Complete data with a median follow-up of 45 months (3-120) were available for 914 patients with HbA1c < 6.5% (n = 227, 24.9%), 6.5-8.4% (n = 532, 58.5%) and ≥ 8.5% (n = 152, 16.6%). Early major surgical complication rate was similar across the groups ranging from 2.6 to 3.3%. No associations between high preoperative HbA1c and late complications-medical as well as surgical-was observed. Groups 2 and 3 had statistically significant more pronounced inflammatory status. LOS (1.8-1.9 days), readmission rates (1.7-2.0%) and surgical time was similar across the three groups. CONCLUSION: Elevated HbA1c is not associated with more early or late postoperative complications, longer LOS, longer surgical time or higher rates of readmission.

Mid-term outcomes after single anastomosis sleeve ileal (SASI) bypass in treatment of morbid obesity.

BACKGROUND: According to several short-term studies, single-anastomosis sleeve ileal (SASI) bypass offers similar weight loss to Roux-en-Y Gastric Bypass (RYGB) with fewer complication and better comorbidity reduction/resolution. Long-term data on this operation is lacking in the literature. The purpose of this study was to analyze the outcomes of SASI bypass up to 4 years. METHODS: This study is a retrospective cohort analysis of 366 patients with morbid obesity who underwent primary SASI bypass from January 2018 to February 2022. RESULTS: The mean age and preoperative body mass index (BMI) were 41 years (range 22-71 years) and 43.9 ± 6.5 kg/m2, respectively. Follow-up was available for 229 patients at 1-year (89%), 112 patients at 2-year (75%), 61 patients at 3-year (75%), and 35 patients at 4-year (71%). The intraoperative, short-term, and long-term complication rates were 0%, 2.5%, 4.6%, respectively. After 4 years, mean percentage excess weight loss (%EWL) was 93.3% and total weight loss (%TWL) was 41.2%. Remission of comorbidities was 93% for type 2 diabetes mellitus, 73% for hypertension, 83% for hyperlipidemia, 79% for sleep apnea, and 25% for gastroesophageal reflux disease (GERD). Biliary gastritis and ulcers are seldom. Eight patients developed de novo GERD symptoms requiring proton pump inhibitor treatment. None of the patients in our study had hypoalbuminemia or malabsorption that did not respond to increased protein intake and vitamin or mineral supplementation. CONCLUSION: SASI bypass appears to be safe, and one of the most effective bariatric procedures regarding weight loss and obesity related comorbidities. The double-outlet created in this procedure seemingly minimizes nutritional complications.

[Vitamin D status before and after metabolic and bariatric surgery at Landspitali].

INTRODUCTION: Long-term results from bariatric surgery amongst individuals with obesity is considered good in general, with regard to weight loss, complications of obesity or quality of life. However, risk of nutrient deficiency might be increased. The aim of the study was to assess vitamin D status of patients before and after metabolic and bariatric surgery at Landspitali. METHODS: Data on 25(OH)D concentration and parathyroid hormone (PTH) was retrieved from medical records for patients undergoing metabolic and bariatric surgery at Landspitali from 2001-2018 (n=539). Insufficient vitamin D status was defined as 25(OH)D concentration p<45 nmol/L in 2001-2012 but p<50 nnmol/L from 2013-2018, due to changes in analytical method during the study period. Vitamin D deficiency was defined as 25(OH)D p<30 nmol/L for both time periods. Guidelines on supplement use are provided before discharge from the hospital and up to 18 months after surgery, RESULTS: Mean concentration of 25(OH)D before surgery was 51 nmol/L (SD 30 nmol/L) and 278 (52%) had insufficient vitamin D status, of which quarter of subjects were defined as being vitamin D deficient. Concentration of 25(OH)D increased after surgery in majority of subjects (85%). However, about third of those defined as having insufficient vitamin D status before surgery still had insufficient status 18 months after surgery. When comparing time periods, 2001-2012 and 2013-2018 it can be seen that insufficient vitamin D status was less common in the second period, although still persistent in about 25% of cases before surgery and 8,5% 18 months after surgery. CONCLUSION: Insufficient vitamin D status is relatively common before metabolic and bariatric surgery at Landspitali. In large majority of subjects, 25(OH)D concentration increased after surgery, following recomendations on supplement intake. The results highlight the need for greater emphasis on correcting possible nutrient deficiencies before surgery.

The mesenteric defects in laparoscopic Roux-en-Y gastric bypass: 5 years follow-up of non-closure versus closure using the stapler technique.

BACKGROUND: Internal hernia (IH) is a common complication of laparoscopic Roux-en-Y gastric bypass (LRYGB). Little large-volume data exist on how to handle the mesenteric defects during LRYGB. This study evaluated long-term follow-up (5.5 years) of 2443 patients with primary closure of the mesenteric defects with a stapling device at LRYGB, in comparison with a non-closed group from the same centre. METHODS: All patients (N = 4013) undergoing LRYGB over a 10-year period (2005-2015) at a single institution were evaluated. The mesenteric defects were routinely closed starting June 2010. In total, 1570 non-closure patients and 2443 patients with stapled closure of the defects were prospectively entered and the results analysed. RESULTS: Closure of the mesenteric defects increased surgical time by 4 min and did not affect the 30-day complication rate. IH incidence was significantly lower (2.5%) in the closure group compared with 11.7% in the non-closure group, at 60 months. The relative risk reduction by closing the mesenteric defects was 4.09-fold (95% CI = 2.97-5.62) as calculated using a survival model. CONCLUSIONS: Internal hernia after LRYGB occurs frequently if mesenteric defects are left unclosed. Primary closure with a hernia-stapling device is safe and significantly reduces the risk of internal hernia.

Genetics of gene expression and its effect on disease.

Common human diseases result from the interplay of many genes and environmental factors. Therefore, a more integrative biology approach is needed to unravel the complexity and causes of such diseases. To elucidate the complexity of common human diseases such as obesity, we have analysed the expression of 23,720 transcripts in large population-based blood and adipose tissue cohorts comprehensively assessed for various phenotypes, including traits related to clinical obesity. In contrast to the blood expression profiles, we observed a marked correlation between gene expression in adipose tissue and obesity-related traits. Genome-wide linkage and association mapping revealed a highly significant genetic component to gene expression traits, including a strong genetic effect of proximal (cis) signals, with 50% of the cis signals overlapping between the two tissues profiled. Here we demonstrate an extensive transcriptional network constructed from the human adipose data that exhibits significant overlap with similar network modules constructed from mouse adipose data. A core network module in humans and mice was identified that is enriched for genes involved in the inflammatory and immune response and has been found to be causally associated to obesity-related traits.

Failed Roux-en-Y Gastric Bypass-Long-Term Results of Distalization with Total Alimentary Limb Length of 250 or 300 cm.

BACKGROUND: Weight loss failure or weight regain may occur after Roux-en-Y gastric bypass (RYGB). Revisional surgery includes distalization. However, few studies have looked at the associations between the total alimentary limb length (TALL) and weight loss outcomes, none with long-term results. OBJECTIVES: Peri- and postoperative outcomes were assessed after employing TALL of either 250 cm or 300 cm in the failed RYGB. METHODS: This study is a retrospective cohort analysis of 90 patients that underwent laparoscopic distalization between January 2006 and January 2016 due to failed RYBG. The index RYGB was modified to TALL of 250 cm (n = 48) or of 300 cm (n = 42) which entailed elongating the bilio-pancreatic limb (BPL) and transposing the Roux limb (RL) to a common limb (CL) of 100 cm and 150 cm, respectively. Long-term weight loss outcomes along with nutritional and vitamin status were analyzed. RESULTS: Preoperative BMI at distalization was 38.6 kg/m2. After 8 years, excess weight loss (EWL) was 61.8%. No differences between the two groups were seen in weight loss outcomes or early surgical complication rates (6.7%). However, more vitamin and nutritional deficiencies were present in the TALL 250-cm group (50.0% and 35.4%, respectively) versus the TALL 300-cm group (33.3% and 14.3% respectively), which led to laparoscopic revision in 27 patients by lengthening the TALL with 100 cm. Patients with weight regain after index RYGB had in average 59.9% higher EWL than patients with EWL failure. CONCLUSION: Distalization of the failed RYGBP is safe and effective, but TALL should not be shorter than 300 cm (and CL 150 cm) due to high rates of malnutrition. Adequate supplementation and long-term follow-up are mandatory to prevent serious malnutrition.

Roux-en-Y Gastric Bypass Reversal: A Novel Technique With Functional Reversal - Case Series.

BACKGROUND: Reversal of Roux-en-Y gastric bypass (RYGB) to normal anatomy (NA) is mandated in selected cases. However, reversal operations are associated with high complication rates and long operative times. In this study, we present the functional reversal (FR) as a novel method and an alternative to reversal to NA in treating the otherwise intractable symptoms rarely occurring after RYGB. METHODS: This is a retrospective cohort study of RYGB-patients with symptoms resistant to non-surgical treatment. Placement of gastrostomy tube for surgical evaluation and optimization of patients was usually done before FR. Resolution of symptoms was assessed along with efficacy and safety of the procedure. Achieved results were compared with data from the literature pertaining to reversal to NA. SETTINGS: High-volume bariatric center, Norway. RESULTS: Ten patients underwent FR. Mean follow-up after reversal was 18.4 months. Symptoms leading to operation improved in all patients. Eight patients suffered from hypoglycemia; resolution was seen in six and improvement of symptoms in the remaining two. Food intolerance, early dumping, nausea, postprandial abdominal pain, and malnutrition were alleviated in all patients. One leak was seen. Mean surgical time was 35.2 min. Total weight loss (TWL) and excess weight loss (EWL) after index RYGB were reduced 4.5% and 17.8%. CONCLUSION: Functional reversal looks promising as an alternative to reversal to normal anatomy as it is technically simpler and safer and seems at least as effective in treating otherwise refractory symptoms.

Limb Length in Gastric Bypass in Super-Obese Patients-Importance of Length of Total Alimentary Small Bowel Tract.

BACKGROUND: In super-obese patients, rates of weight loss failure and weight regain are high after RYGB. In order to improve weight loss, lengthening of the biliopancreatic limb is vital. In this study, efficacy and safety of two types of RYGB with 2-m BP-limb were assessed in improving weight loss and in the resolution of comorbidities compared with standard RYGB in a long-term follow-up. METHODS: This is a retrospective cohort analysis on 671 super-obese patients operated in a 10-year period. Patients were classified into three groups: (1) 155 patients; roux limb 150 cm, BP-limb 60 cm; (2) 230 patients; roux limb 60 cm, BP-limb 200 cm; and (3) 286 patients; roux limb 150 cm, BP-limb 200 cm. EWL, TWL, BMI, failure, weight regain, comorbidity resolution, nutritional status, and complications were assessed. RESULTS: Total alimentary limb length was shortened with 60 cm in group 1 and with 200 cm in groups 2 and 3. EWL, BMI change, and TWL were higher in the 2-m BP-limb groups vs group 1. No differences in complication rates were found, except higher frequency of marginal ulcers in patients with a shorter roux limb. EWL failure was higher in group 1 (10.3%) vs the other groups (4.3%; 5.2%). Group 3 had significantly less weight regain (26.6%). Remission of comorbidities was higher in the 2-m BP-limb groups at expense of nutritional and vitamin deficiencies (3.9%; 5.9%). No difference in hypoalbuminemia was noted. CONCLUSION: Lengthening of the BP-limb gives significantly higher weight loss, lower rate of EWL failure, and lesser weight regain along with better resolution of obesity-associated comorbidities.

Distal gastric bypass: 2-m biliopancreatic limb construction with varying lengths of common channel.

BACKGROUND: Long-term durability after Roux-en-Y gastric bypass is challenging in the super-obese population. Although lengthening of biliopancreatic limb (BPL) is associated with higher rates of weight loss, shortening of common limb (CL) is related to higher risk of malabsorption. OBJECTIVES: In this study, we aimed at evaluating the importance of the total alimentary limb length by creating a 2-m BPL diversion with varying CL lengths. SETTING: High-volume bariatric center, Norway. METHODS: Three groups of patients (N = 187) with different limb lengths were included in this retrospective cohort-analysis as follows: group 1 (n = 69; Roux limb = 150 cm, BPL = 60 cm), group 2 (n = 88; BPL = 200 cm, CL = 150 cm), and group 3 (n = 30; BPL = 200 cm, CL = 200 cm). Weight loss, regain, and failure were analyzed along with malabsorption issues. RESULTS: Preoperative body mass index (BMI) was higher in group 2 (58.5, P < .001) and 3 (57.4) versus group 1 (54.6, P = .011). No other clinically significant differences between the groups were noted. Follow-up rate was 95% at year 2, 74% at year 5, and 52% at year 10. At 10-year follow-up, excess weight loss and total weight loss was higher in group 2 (70.4%; 40.3%) and 3 (64.0%; 35.9%) compared with group 1 (55.9%; 29.2%). Excess weight loss failure was higher in group 1 versus 2 (30% versus 8.3%, P < .001). No difference in short- or long-term complications was seen except higher occurrence of internal hernia in distal Roux-en-Y gastric bypass groups (11.4%, 6.7%). Vitamin and mineral deficiencies occurred more frequently the shorter the CL was. CONCLUSION: Sustainable weight loss in a long-term follow-up is achieved by shortening the total alimentary limb length with a 2-m BPL diversion that should not be attached <200 cm from the ileocecal junction owing to higher rates of internal hernia and vitamin and mineral deficiencies.

[Laparoscopic gastric bypass surgery in extreme overweight at a private hospital]. / Laparoskopisk gastrisk bypass ved ekstrem overvekt ved et privatsykehus.

BACKGROUND: Laparoscopic gastric bypass surgery leads to significant weight loss and reduced morbidity in patients with severe obesity. The technique was introduced at the private Aleris hospital the autumn 2005. We here present the method and results from our initial experience. MATERIAL AND METHODS: Inclusion criteria were BMI > 40 kg/m2 or BMI 35-39,9 kg/m2 , with obesity-related co-morbidity for more than 5 years and insufficient effect of conservative treatment. The first 121 (103 women) consecutive patients who underwent gastric bypass surgery at Aleris Hospital were included. Characteristics were; mean age 40 years (18-68), mean preoperative body weight 134 kg (91-211) and BMI 44 m/kg 2 (35-64). Serious complications or major morbidity were defined as anastomosis- or intestinal leakage and bleeding requiring surgical treatment. RESULTS: No deaths or major morbidity was observed the first 30 days after surgery. One patient underwent successful surgery of a perforated ulcer localized distally to the gastro-jejunal anastomoses 3 months p.o. Mean operating time was 62 min (40-124) for patients who underwent isolated laparoscopic bypass. The mean hospitalisation time was 2.9 days (2-6). CONCLUSION: Our results demonstrate that bariatric surgery can be established successfully with a low rate of perioperative complications. We believe that thorough planning and experienced bariatric surgeons contribute to our favourable results. .

[Outcome of gastric bypass surgery in Iceland 2001-2015].

INTRODUCTION: Laparoscopic roux-en-y gastric bypass (LRYGB) has been performed at Landspitali University Hospital (LSH) since 2001. The procedure represents an important treatment option for morbidly obese patients. The aim of this study is to evaluate the long-term results of these operations in Iceland. MATERIAL AND METHODS: All 772 consecutive patients undergoing LRYGB at LSH during 2001-2015 were included. Information was collected from a prospective database. Successful weight loss was defined as body mass index (BMI) less than 33 kg/m2 or excess body mass index loss (EBMIL) more than 50%. RESULTS: Mean age of patients was 41 years and 83% were females. Mean pre-operative weight was 127 kg (±20) and mean BMI was 44 (±6). Mean %EBMIL was 80% after 1.5 year, 70% after 5 years and 64% after 10-13 years. 85% of patients had successful weight loss with a mean follow-up time of 7.4 years. Pre-operatively patients on average had 2.8 obesity related comorbid diseases. 71% of patients with type 2 diabetes were in full remission after surgery. One third of patients with hypertension and one third of patients with hyperlipidemia achieved full remission after surgery. 37 patients (5%) had an early complication and 174 (25%) had a late complication that frequently needed surgical solution. Most patients (78%) needed repeated adjustment of vitamins and minerals often many years after surgery. CONCLUSION: Majority of patients achieved a successful weight loss and most obesity related comorbidities are still in remission 7.4 years after surgery. Early complications were rare but one fourth of patients had late complications. Life long follow-up is of utmost importance after gastric bypass surgery. Key words: gastric bypass surgery in Iceland 2001-2015. Correspondence: Hjörtur Gíslason, hjorturg@landspitali.is.

Long-term effects of laparoscopic Roux-en-Y gastric bypass on metabolic syndrome in patients with morbid obesity.

BACKGROUND: Diseases associated with obesity such as type 2 diabetes (T2D), hypertension, and dyslipidemia are common and together are defined as metabolic syndrome (MetS). The aim of this study was to evaluate long-term effects of laparoscopic Roux-en-Y gastric bypass (LRYGB) in morbidly obese patients with MetS. METHODS: This was a retrospective study of data from a prospective database in a single center from 2005 to 2013 including 3795 LRYGB operated obese patients. Metabolic syndrome was defined according to the International Diabetes Federation Consensus Definition of Metabolic Syndrome from 2006. RESULTS: In the study population, 79% of the patients were women, the preoperative median age was 42.4 years, and median body mass index (BMI, kg/m2) was 40.9. MetS was diagnosed in 60% of the patients (2275/3795), with increased frequency in men and in those with higher age, higher BMI, and greater waist circumference; 27.5% of patients had impaired glucose metabolism, 40% hypertension, and 30% dyslipidemia. Postoperative follow-up rate>5 years was 71% (595/839). We found that 86.2% had resolution of MetS. After 5-9 years, complete remission of T2D was achieved in 78%, hypertension in 51%, and dyslipidemia in 89%. Mean excess BMI loss was significantly lower for patients with MetS (73.1%) compared with patients without MetS (75.6%) (P<.01). Early complications (leakage or hemorrhage) occurred in 1.2% (48/3975) and internal hernia in 7.8% (310/3975). Presence of MetS did not increase complication rates. CONCLUSION: LRYGB in obese patients is associated with a significant and sustained reduction in excessive weight. In the present study, 86.2% of patients with MetS achieved complete remission and complication rates were low. Early bariatric surgery should be considered in patients with obesity and concurrent MetS.

Laparoscopic Roux-en-Y gastric bypass with 2-metre long biliopancreatic limb for morbid obesity: technique and experience with the first 150 patients.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (RYGBP) is being performed widely as a treatment of choice for morbid obesity. We present our method and experience with the first 150 consecutive cases of laparoscopic RYGBP with a 2-m long biliopancreatic limb (BP-limb). METHODS: Between November 2001 and November 2003, a prospective analysis of 150 patients was performed identifying technical success and complications. Before surgery, patients underwent a strict multidisciplinary behavioral program. At operation the stomach was transected proximally with a linear stapler (60-mm, Endo-GIA) to create a prolongation of the esophagus (gastric tube) along the lesser curvature, resulting in a 40-50 ml pouch. Two meters of the proximal jejunum were bypassed (BP-limb), creating an antecolic Roux-en-Y gastro-jejunostomy to the posterior wall of the gastric tube using a 45-mm linear Endo-GIA stapler. The entero-anastomosis was created 50 cm below the gastro-jejunostomy, also with a 45-mm linear Endo-GIA. RESULTS: Mean BMI was 50.0, and 78% of patients were females. With 100% follow-up, we found an EWL of 50% 6 months after surgery, gradually rising to 80% after 18 months. The mean operating time was 116 min for the first 50 cases and decreased to 82 min for the last 50 cases. Intestinal leakage occurred in 5 patients (3%) and bleeding in 5 (3%). Most of these complications occurred in the first 50 cases, and all but one were treated successfully with an early laparoscopic re-operation. Marginal ulcers were found in 16.6% of patients. No internal hernias have occurred. CONCLUSION: The operation demands advanced laparoscopic skills, but technically it is relatively simple and has an acceptable complication rate. Short-term results regarding excess weight loss are at least comparable to the RYGBP with a long alimentary limb.

Mucosal glucagon-like peptide-1 and glucose-dependent insulinotropic polypeptide cell numbers in the super-obese human foregut after gastric bypass.

BACKGROUND: Super-obesity, a body mass index>50 kg/m(2), is difficult to treat. Many studies have focused on the anatomic changes of the intestines; the physiologic background is not clearly identified. It is established that Roux-en-Y gastric bypass (RYGB) augments secretion of glucagon-like peptide-1 (GLP-1), peptide tyrosine tyrosine (PYY), and insulin, but other aspects of gut hormone cell function in the alimentary limb are unknown. OBJECTIVE: To study the effects of laparoscopic RYGB on enteroendocrine cells. SETTING: University-affiliated, high-volume bariatric surgery center. METHODS: Eighteen nondiabetic patients were drawn from the present study (NCT 01514799), randomizing between biliopancreatic (BP) limbs of either 60 cm (BP60) or 200 cm (BP200). Demographic characteristics did not differ at baseline or 12 months. Pouch and jejunal biopsies were obtained intraoperatively and using endoscopy at 12 months. Mucosal height and density of hormone-producing cell populations were assessed and mRNA expression measured with real-time polymerase chain reaction. RESULTS: In perianastomotic jejunum, a 4.9-fold increase in GLP-1 cell density was evident 12 months after RYGB, most pronounced in the BP200-group. The densities of glucose-dependent insulinotropic polypeptide (GIP) cells and PYY immunoreactive cells were doubled after 12 months. GIP mRNA was unaffected, but GLP-1 and PYY mRNA were lower 12 months after RYGB. RYGB had no impact on villi length or density of ghrelin-, cholecystokinin-, neurotensin-, secretin-, or serotonin-producing cells after 12 months. Pouch mucosal height and cell densities of ghrelin-, histamine-, serotonin-, and somatostatin-producing cells remained unaffected by RYGB in both groups. CONCLUSIONS: RYGB selectively increased the density of incretin-producing cell populations in the jejunum. This may provide anatomic explanation for the observed increased plasma levels of incretins.

Gastric mucosal exposure to histamine in rats is followed by absorption of histamine but not mucosal hyperemia.

BACKGROUND/AIMS: Superficial mucosal damage is associated with mucosal hyperemia and release of histamine into venous blood and gastric lumen. This study was designed to examine if histamine administrated directly to gastric mucosa becomes absorbed and transported away with blood, and if so whether it is capable of increasing gastric mucosal blood flow. METHODOLOGY: Superficial mucosal injury was induced by exposing chambered rat stomachs to 2 M NaCl for 10 min, and 45 min later 4.5 x 10(-2) or 4.5 x 10(-3) M histamine was instilled into the chamber. Mucosal blood flow was determined by radioactive microspheres and continuously by Laser Doppler flowmetry. RESULTS: Histamine concentration in arterial blood was markedly increased 15 min after administration of histamine. The mucosal blood flow did not increase after application of histamine. Significant increase in heart rate and fall in arterial blood pressure were observed. Similar results were obtained after application of histamine to normal mucosa. CONCLUSIONS: Histamine applied to injured or normal gastric mucosa of rats becomes transported via capillaries and venules to the systemic circulation, but does not reach terminal arterioles in quantities large enough to cause vasodilatation.

Gastric bypass with long alimentary limb or long pancreato-biliary limb--long-term results on weight loss, resolution of co-morbidities and metabolic parameters.

BACKGROUND: Several studies indicate that increasing the alimentary limb length in gastric bypass surgery produces only a minor improvement of excess BMI loss. Few studies have addressed the efficacy of increasing the length of the pancreatico-biliary limb. METHODS: Here, we present a prospective randomized study of 187 consecutive laparoscopic Roux-Y gastric bypass operations operated over 2 years (2004-2005) in Iceland. The patients were operated with a gastric bypass with either a 2-m biliopancreatic (BP)-limb and a 60-cm alimentary (A)-limb (n = 93) or with a 150-cm A-limb and a 60-cm BP-limb (n = 94). RESULTS: Preoperative median BMI was 44.1 (38-70), median age 35.5 (17-74) years, and 85 % of the patients were female. Follow-up rate after 5 years was 85 %. Eighteen months following surgery, the weight loss was significantly higher in the BP-limb group (p < 0.001), and this difference remained 7 years after surgery. Weight regain occurred in both groups, and 7 years after surgery, excess BMI loss (EBMIL) was 78.4 % in the BP-limb group compared to 67.1 % in the A-limb group (p < 0.001). Most patients (78 %) needed supplementation adjustment (iron, vitamin D and calcium) during the study period, significantly more often in the BP-limb group compared to the A-limb group (p < 0.001). Patients in the BP-limb group had more frequent stools than patients in the A-limb group; otherwise, gastro-intestinal symptoms rating scoring were comparable. Complication rate was similar. CONCLUSIONS: Gastric bypass with a 2-m BP-limb gives better weight loss than gastric bypass with a 60-cm BP-limb and a 150-cm A-limb. Metabolic follow-up is of utmost importance, as most patients needed repeated adjustments of their supplementation.

Tensile strength after closure of mesenteric gaps in laparoscopic gastric bypass: three techniques tested in a porcine model.

BACKGROUND: Internal hernias occur frequently after laparoscopic gastric bypass. We have found no data on the relative strength of the various techniques available for closing these defects. The present study was performed to obtain such data to form a theoretical basis for clinical studies. METHODS: Six piglets were operated laparoscopically and four loops of small bowel created in each. These mesenteric gaps were closed over a distance of 40 mm using (1) running 2-0 Ethibond® suture, (2) Endo Hernia stapler, (3) fibrin glue (Tisseel®) and (4) controls, where the mesenteric surfaces were rubbed with a sponge and approximated without further intervention. After 6 weeks, the different segments of the mesentery were excised. The tensile strength was measured using continuously increased traction until the closure ruptured. The ordinary mesentery served as the control. The breaking tension and total amount of energy transferred to the tissue were registered. RESULTS: Control areas with rubbed areas developed no adhesions. Suture and staple lines contracted by 30 % in length, whereas the fibrin glued lines were even shorter. Median tensile strength was greatest for the sutured lines (14,293 mN) and stapled lines (10,798 mN). Fibrin glued lines were significantly weaker (6,780 mN, p = 0.013 and p = 0.026), but as strong as ordinary mesentery (4,165 mN). CONCLUSIONS: If ongoing controlled randomized trials show closure to be beneficial, further studies should include staples as one of the options for the closure of mesenteric defects. The role of fibrin glue needs to be further investigated.

Internal hernia after gastric bypass: a new and simplified technique for laparoscopic primary closure of the mesenteric defects.

BACKGROUND: Bowel obstruction due to internal hernia is a well-known complication of laparoscopic Roux-en-Y gastric bypass (LRGB). Increasing evidence supports primary closing of the mesenteric defects, but controversy continues about surgical technique of systematic closure. This paper reviews our experience with internal hernia after LRGB and describes a new method of preemptive closure of the mesenteric defects. MATERIAL AND METHODS: Two thousand four hundred seventy-two consecutive patients undergoing LRGB from September 2005 to June 2010 were entered into our prospective longitudinal database. The mesenteric defects were not closed. Patients entered a 5-year follow-up program, and all who subsequently presented with internal hernia were analyzed. A further 1,630 patients operated on in the last 12 months were subjected to our new technique of closing the defects; data were entered in our own database as well as in the Scandinavian quality registry. Follow-up time for these patients is limited. RESULTS: In the first group, 117 patients developed an internal hernia (4.7%) at a mean interval after LRGB of 13 (range, 4-43 months). Four patients needed bowel resections because of severe ischemia. There was one death associated with complication of the internal hernia. In the primary closure group, four patients early in the series had reoperations for kinking of the enteroanastomosis. There have been no mesenteric haematomas encountered. CONCLUSIONS: Internal hernia should be ruled out in patients with previous LRGB and abdominal pain. Our technique for primary closing of the mesenteric defects seems to be safe and is so far promising.