Effects of a single subanaesthetic dose of ketamine on pain and mood after laparoscopic bariatric surgery: A randomised double-blind placebo controlled study.

BACKGROUND: When administered as a continuous infusion, ketamine is known to be a potent analgesic and general anaesthetic. Recent studies suggest that a single low-dose administration of ketamine can provide a long-lasting effect on mood, but its effects when given in the postoperative period have not been studied. OBJECTIVE: We hypothesised that a single low-dose administration of ketamine after bariatric surgery can improve pain and mood scores in the immediate postoperative period. DESIGN: We performed a randomised, double-blind, placebo-controlled study to compare a single subanaesthetic dose of ketamine (0.4 mg kg) with a normal saline placebo in the postanaesthesia care unit after laparoscopic gastric bypass and gastrectomy. SETTING: Single-centre, tertiary care hospital, October 2014 to January 2018. PATIENTS: A total of 100 patients were randomised into the ketamine and saline groups. INTERVENTION: Patients in the ketamine group received a single dose of ketamine infusion (0.4 mg kg) in the postanaesthesia care unit. Patients in the placebo groups received 0.9% saline. OUTCOME MEASURES: The primary outcome was the visual analogue pain score. A secondary outcome was performance on the short-form McGill's Pain Questionnaire (SF-MPQ). RESULTS: There were no significant differences in visual analogue pain scores between groups (group-by-time interaction P = 0.966; marginal group effect P = 0.137). However, scores on the affective scale of SF-MPQ (secondary outcome) significantly decreased in the ketamine group as early as postoperative day (POD) 2 [mean difference = -2.2 (95% bootstrap CI -2.9 to 1.6), Bonferroni adjusted P < 0.001], compared with placebo group in which the scores decreased only by POD 7. Scores on the total scale of SF-MPQ for the ketamine group were smaller compared with the placebo group (P = 0.034). CONCLUSION: Although there was no significant difference between ketamine and placebo for the primary outcome measure, patients who received ketamine experienced statistically and clinically significant improvement in their comprehensive evaluation of pain, particularly the affective component of pain, on POD 2. However, future studies are needed to confirm the enduring effects of ketamine on the affective response to postoperative pain. CLINICAL TRIAL REGISTRATION: NCT02452060. : This article is accompanied by the following Invited Commentaries:Mion G. Ketamine stakes in 2018. Right doses, good choices. Eur J Anaesthesiol 2019; 36:1-3.Robu B, Lavand'homme, P. Targeting the affective component of pain with ketamine. A tool to improve the postoperative experience? Eur J Anaesthesiol 2019; 36:4-5.

Intraoperative leak testing has no correlation with leak after laparoscopic sleeve gastrectomy.

BACKGROUND: Staple line leak is a serious complication of sleeve gastrectomy. Intraoperative methylene blue and air leak tests are routinely used to evaluate for leak; however, the utility of these tests is controversial. We hypothesize that the practice of routine intraoperative leak testing is unnecessary during sleeve gastrectomy. METHODS: A retrospective cohort study was designed using a prospectively collected database of seven bariatric surgeons from two institutions. All patients who underwent sleeve gastrectomy from March 2012 to November 2014 were included. The performance of intraoperative leak testing and the type of test (air or methylene blue) were based on surgeon preference. Data obtained included BMI, demographics, comorbidity, presence of intraoperative leak test, result of test, and type of test. The primary outcome was leak rate between the leak test (LT) and no leak test (NLT) groups. SAS version 9.4 was used for univariate and multivariate analyses. RESULTS: A total of 1550 sleeve gastrectomies were included; most were laparoscopic (99.8%), except for one converted and two open cases. Routine intraoperative leak tests were performed in 1329 (85.7%) cases, while 221 (14.3%) did not have LTs. Of the 1329 cases with LTs, there were no positive intraoperative results. Fifteen (1%) patients developed leaks, with no difference in leak rate between the LT and NLT groups (1 vs. 1%, p = 0.999). After adjusting for baseline differences between the groups with a propensity analysis, the observed lack of association between leak and intraoperative leak test remained. In this cohort, leaks presented at a mean of 17.3 days postoperatively (range 1-67 days). Two patients with staple line leaks underwent repeat intraoperative leak testing at leak presentation, and the tests remained negative. CONCLUSION: Intraoperative leak testing has no correlation with leak due to laparoscopic sleeve gastrectomy and is not predictive of the later development of staple line leak.

Safety of laparoscopic adjustable gastric banding with concurrent cholecystectomy for symptomatic cholelithiasis.

BACKGROUND: The prevalence of cholelithiasis correlates with obesity. Patients often present for bariatric surgery with symptomatic cholelithiasis. There is a concern of cross-contamination when performing laparoscopic adjustable gastric banding (LAGB) with concurrent cholecystectomy. The primary goal of this study is to address the safety and feasibility of this practice. METHODS: A retrospective cohort study was designed from a prospectively collected database. All LAGB patients from July 2005 to April 2013 were included. Patients undergoing LAGB with concurrent cholecystectomy comprised the study group (LAGB/chole). The control group (LAGB) consisted of patients undergoing LAGB alone, and was selected using a 3:1 (control:study) case-match based on demographic and comorbidity data. The primary outcome was overall complication rate, with secondary outcomes including operating room (OR) time, length of stay (LOS), 30-day readmission/reoperation, erosion, infection, and band/port revisional surgery. RESULTS: There were 4,982 patients who met criteria. Of these, 28 patients had a LAGB with concurrent cholecystectomy, comprising the LAGB/chole (study) group. The remaining 4,954 patients were eligible controls, of which 84 were selected for the LAGB (control) group. Demographic and comorbidity data, along with mean follow-up time, were similar between the two groups. OR time was longer in the LAGB/chole group, but LOS was the same. The overall complication rate in the LAGB/chole group was 21 (n = 6) versus 20% (n = 17) in the LAGB group (p = 0.893). Thirty-day readmission and reoperation were similar. There was also no difference in port site, wound, and intra-abdominal infections. There were no band erosions in either group. CONCLUSIONS: Performing a concurrent cholecystectomy at the time of LAGB does not result in increased immediate or delayed morbidity. Although longer to perform, this safe operation would avoid a second surgery for a patient already diagnosed with symptomatic cholelithiasis.

Sustained weight loss after gastric banding revision for pouch-related problems.

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.

Single-stage versus 2-stage sleeve gastrectomy as a conversion after failed adjustable gastric banding: 30-day outcomes.

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.

Location and number of sutures placed for hiatal hernia repair during laparoscopic adjustable gastric banding: does it matter?

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.

Does adding a lesser-curvature gastrogastric plication suture reduce the need for revision after laparoscopic adjustable gastric band placement?

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.

First-year weight loss following gastric band surgery predicts long-term outcomes.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) continues to be a valid surgical treatment option to address severe obesity. However, outcomes are varied and can be difficult to predict. Early prediction of suboptimal weight loss following LAGB may enable adjustments to postoperative care and consequently improve surgical outcomes. Therefore, our aim is to investigate the prognostic utility of using early weight loss following LAGB to predict long-term weight outcomes. METHODS: Clinical data from patients undergoing LAGB between 2001 and 2007 at a single institution were retrospectively collected and analysed. The data was used to inform a model for predicting long-term weight loss after LAGB surgery. Percent total weight loss (%TWL) greater than 20% 1 year after surgery was considered a measurement of success since it has been associated with the improvement of comorbidities and increased patient satisfaction. RESULTS: The average %TWL 1 year after LAGB surgery was 23.73% (n = 1524, SD = 8.68%). Weight loss of less than 10% in 1 year was a negative predictor of weight loss >20% in 8-12 years (OR = 0.449; p = 0.002; 95% CI = 0.272-0.742). Moreover, weight loss >20% in 1 year was a strong predictor of weight loss >20% in 8-12 years (OR = 5.33; p < 0.001; 95% CI = 3.17-8.97). CONCLUSION: Total body weight reduction of less than 10% 1 year after LAGB surgery suggests a lesser weight loss at 8-12 years. For these patients, targeted interventions would be appropriate to increase the chances of long-term success.

The Effect of Laparoscopic Sleeve Gastrectomy on Gastroesophageal Reflux Disease.

BACKGROUND: The laparoscopic sleeve gastrectomy (LSG) has become one of the most popular surgical weight loss options. Since its inception as a procedure intended to promote durable weight loss, the association between LSG and gastroesophageal reflux disease (GERD) has been a point of debate. First and foremost, it is known that GERD occurs more frequently in the obese population. With the sleeve gastrectomy growing to be the predominant primary bariatric operation in the United States, it is imperative that we understand the impact of LSG on GERD. OBJECTIVE: To examine the effects of LSG on GERD symptoms. METHODS: One hundred and ninety-one bariatric surgery candidates completed a Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire before and after undergoing elective LSG (mean follow-up time of 20.4 ± 2.7 months). Values were stratified by the presence or absence of preoperative GERD, GERD medications, age, gender, crural repair, patient satisfaction with present condition, and percent total weight loss (%TWL). RESULTS: For the entire group, mean weight loss, %TWL, and reduction in BMI were 79 pounds, 28.1%, and 12.7 kg/m2 respectively. Within the overall cohort, there was no significant change in GERD symptoms from before to after surgery (mean GERD-HRQL scores were 6.1 before and after surgery, p = 0.981). However, in a subgroup analysis, patients without GERD preoperatively demonstrated a worsening in mean GERD-HRQL scores after surgery (from 2.4 to 4.5, p = 0.0020). The percentage of change in the usage of medications to treat GERD was not statistically significant (from 37 to 32%, p = 0.233). The percent of patients satisfied with their condition postoperatively was significantly increased in those with preoperative GERD, older age, crural repair intraoperatively, and in those with the highest %TWL. CONCLUSION: These results suggest that while overall LSG does not significantly affect GERD symptoms, patients without GERD preoperatively may be at risk for developing new or worsening GERD symptoms after surgery. It is important to remark that this is a review of the patient's clinical symptoms of GERD, not related to any endoscopic, pathological, or manometry studies. Such studies are necessary to fully establish the effect of LSG on esophageal health.

Safety of the laparoscopic adjustable gastric band: 7-year data from a U.S. center of excellence.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) has become one of the most common weight-loss procedures performed in the United States. The authors' high-volume academic medical center has gathered a database of almost 3,000 patients who have undergone LAGB since January 2001. The goal of this series, the largest to date on LAGB outcomes at a single institution, was to assess complications associated with LAGB. METHODS: A retrospective analysis was performed using longitudinal data from adult patients who underwent LAGB between 1 January 2001, and 29 February 2008. General and band-related complications were reported for all patients. Death and reoperation for weight gain (LAGB followed by either a second band insertion or a gastric bypass) also were reported. RESULTS: Of the 2,965 patients who received LAGB during the study period, 2,909 met the criteria for inclusion in this analysis, and 363 (12.2%) experienced one or more complications. The most common complications were band slip (4.5%) and port-related problems (3.3%). Other complications were rare. Only seven patients (0.2%) had band erosion. Eleven patients (0.4%) underwent reoperation for weight gain. A total of 10 deaths (0.34%) occurred during the study period. Three patients died within 30 days of surgery. Two of these deaths (0.06%) were related to surgery, and one resulted from a motor vehicle accident. Seven patients died of causes unrelated to surgery during the course of the study. CONCLUSIONS: The LAGB technique is a relatively safe procedure with few early or late complications. Few LAGB patients undergo reoperation for weight gain, and mortality is very rare.

Lap-band impact on the function of the esophagus.

BACKGROUND: The laparoscopic adjustable gastric band (LAGB) has been widely used to treat morbid obesity. There is conflicting data on its long-term effect on esophageal function. Our aim was to assess the long-term impact of the LAGB on esophageal motility and pH-metry in patients who had LAGB who had normal and abnormal esophageal function at baseline. METHODS: Consecutive patients referred for bariatric surgery were prospectively enrolled. A detailed medical history was obtained, and esophageal manometric and 24-h pH evaluations were performed in standard fashion preoperatively and 6 and 12 months postoperatively; patients served as their own controls. RESULTS: Twenty-two patients completed manometric evaluation. Ten patients had normal manometric parameters at baseline; at 6 months, mean lower esophageal sphincter (LES) residual pressure increased significantly from baseline (3.9 +/- 2 vs. 8.9 +/- 4 mmHg, p = 0.014). At 12 months, the mean peristaltic wave duration increased from 3.6 +/- 1 at baseline to 6.8 +/- 2 s, p = 0.025 and wave amplitude decreased during the same period (98.7 +/- 22 vs. 52.3 +/- 24, p = 0.013). LES pressure and percent peristalsis did not differ significantly pre- and post-LAGB. Twelve patients had one or more abnormal manometric findings at baseline; at 12 months, LES pressure in these 12 patients decreased significantly (31.1 +/- 10 vs 23.6 +/- 7, p = 0.011) and wave amplitude was significantly reduced (125.9 +/- 117 vs 103 +/- 107, p = 0.039). LES residual pressure did not change significantly pre- and post-LAGB. Twenty-two individuals were evaluated for impact of Lap-Band on esophageal acid exposure. Sixteen of these patients had normal esophageal pH-metry values at baseline and had no significant changes in 12 months in any pH-metry measurement. Six patients had abnormal pH-metry values at baseline. Among these patients, time with pH < 4.0 and Johnson/DeMeester score did not change significantly during follow-up. There was a significant decrease in the number of reflux episodes from baseline to 6 months (159 +/- 48 vs. 81 +/- 61, p = 0.016). CONCLUSIONS: Abnormal manometric findings are frequently encountered post-LAGB. Increases in LES residual pressure and peristaltic wave duration were the most significant changes. LAGB is not associated with an increase in total esophageal acidification time. Further evaluation of the clinical significance of manometric abnormalities is warranted.

The effect of laparoscopic gastric banding surgery on plasma levels of appetite-control, insulinotropic, and digestive hormones.

BACKGROUND: We hypothesized that laparoscopic adjustable gastric banding (LAGB) reduces weight and modulates ghrelin production, but largely spares gastrointestinal endocrine function. To examine this hypothesis, we determined plasma concentrations of appetite-control, insulinotropic, and digestive hormones in relation to LAGB. METHODS: Twenty-four patients undergoing LAGB were prospectively enrolled. Body mass index (BMI) was measured and blood samples obtained at baseline and 6 and 12 months post-surgery. Plasma concentrations of leptin, acylated and total ghrelin, pancreatic polypeptide (PP), insulin, glucose-dependent insulinotropic peptide (GIP), active glucagon-like peptide-1 (GLP-1), gastrin, and pepsinogens I and II were measured using enzyme-linked immunoassays. RESULTS: Median percent excess weight loss (%EWL) over 12 months was 45.7% with median BMI decreasing from 43.2 at baseline to 33.8 at 12 months post-surgery (p < 0.001). Median leptin levels decreased from 19.7 ng/ml at baseline to 6.9 ng/ml at 12 months post-surgery (p < 0.001). In contrast, plasma levels of acylated and total ghrelin, PP, insulin, GIP, GLP-1, gastrin, and pepsinogen I did not change in relation to surgery (p > 0.05). Pepsinogen II levels were significantly lower 6 months after LAGB but returned to baseline levels by 12 months. CONCLUSIONS: LAGB yielded substantial %EWL and a proportional decrease in plasma leptin. Our results support the hypothesis that LAGB works in part by suppressing the rise in ghrelin that normally accompanies weight loss. Unchanged concentrations of insulinotropic and digestive hormones suggest that gastrointestinal endocrine function is largely maintained in the long term.

Hiatal hernia repair at the initial laparoscopic adjustable gastric band operation reduces the need for reoperation.

BACKGROUND: Intractable reflux, either due to gastric prolapse or concentric pouch dilatation has been the most common indication for reoperation or band removal after laparoscopic adjustable gastric banding (LAGB). We have previously found that a simple hiatal hernia repair (HHR) leads to remission of these symptoms minimizing the need for band removal. We have subsequently added crural repair/HHR at the initial operation, where indicated. In this study compare the rate of reoperation in patients who underwent LAGB alone, or with concurrent HHR. METHODS: A retrospective review of a prospective database of all patients undergoing LAGB was performed to determine the incidence of reoperation in the two groups. RESULTS: Between July 2001 and August of 2006, 1298 patients underwent LAGB and 520 patients underwent LAGB with concurrent HHR (LAGB/HHR). The mean initial weight and BMI were 128 kg (range, 71.1-245.7 kg) and 45.4 kg/m(2) (range, 28-75 kg/m(2)). Average follow-up for the LAGB and LAGB/HHR groups was 24.8 and 20.5 months, respectively. Rate of reoperation for HHR alone, or with band slip or concentric pouch dilatation, for LAGB and LAGB/HHR groups was 5.6% and 1.7% respectively (p < 0.001). Total reoperation rate for slip, HHR and pouch dilatation was 7.9% and 3.5%, respectively (p < 0.001). There was no significant difference in rate of slip repair alone between the two groups: 2.3% and 1.7%, respectively (p < 0.44). CONCLUSIONS: Adding HHR to LAGB where indicated significantly reduces reoperation rate. Every effort should be made to detect and repair HHR during placement of the band, as it will decrease future need for reoperation.

Gastric banding as a salvage procedure for patients with weight loss failure after Roux-en-Y gastric bypass.

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.

Long-term results for gastric banding as salvage procedure for patients with weight loss failure after Roux-en-Y gastric bypass.

BACKGROUND: Studies reporting revisionary options for weight loss failure after Roux-en-Y gastric bypass (RYGB) have been underpowered and lacking long-term data. We have previously shown that short-term (12 mo) and midterm (24 mo) weight loss is achievable with laparoscopic adjustable gastric banding (LAGB) for failed RYGB. The present study represents the largest published series with longest postoperative follow-up of patients receiving salvage LAGB after RYGB failure. OBJECTIVE: To investigate long-term results of salvage gastric banding. SETTING: University Hospital, New York, United States. METHODS: Data were prospectively collected with retrospective review. Baseline characteristics were evaluated and weights at multiple time intervals (before RYGB, before LAGB, each year of follow-up). Additional data included approach (open or laparoscopic), operative time, hospital length of stay, and postoperative complications. RESULTS: A total of 168 patients underwent statistical analysis with 86 patients meeting inclusion for RYGB failure. The mean body mass index before RYGB was 48.9 kg/m2. Before LAGB, patients had an average body mass index of 43.7 kg/m2, with 10.4% total weight loss and 21.4% excess weight loss after RYGB. At 5-year follow-up, patients (n = 20) had a mean body mass index of 33.6 kg/m2 with 22.5% total weight loss and 65.9% excess weight loss. The long-term reoperation rate for complications related to LAGB was 24%, and 8% of patients ultimately had their gastric bands removed. CONCLUSION: The results of our study have shown that LAGB had good long-term data as a revisionary procedure for weight loss failure after RYGB.

Treatment with lavender aromatherapy in the post-anesthesia care unit reduces opioid requirements of morbidly obese patients undergoing laparoscopic adjustable gastric banding.

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.

Gastric banding at the Royal Brisbane and Women's Hospital: trials and tribulations of a public service.

BACKGROUND: The Royal Brisbane and Women's Hospital provides the only gastric banding service for the public to the state of Queensland. Our patients are potentially a different group from the previously reported Australian series with respect to weight, comorbidities and ease of follow up and we therefore present this series of public patient for comparison of medium-term results. METHODS: The service consists of a dedicated fortnightly clinic. Patients are referred from within the hospital and also from other health services throughout Queensland and northern New South Wales. Resources allow a limited number of gastric bands to be placed annually. At follow up, measurement of weight is carried out and band adjustments made as necessary. Data are collected prospectively on a dedicated database (LapBase; AccessMed, Melbourne, Australia). RESULTS: Sixty-nine laparoscopic gastric bands (Lap Band; Inamed Health, Santa Barbara, CA, USA) have been placed as a public service at Royal Brisbane and Women's Hospital since August 2001 in 50 women and 19 men. The mean body mass index (BMI) at surgery was 53 kg/m2 (range 33-81 kg/m2). The mean percentage of excess bodyweight lost at 1, 2 and 3 years is 38.5, 45.7 and 57.9%, respectively. The mean BMI has reduced from the baseline of 53 to 44.5 at 1 year, 41.8 at 2 years and 38.6 at 3 years. The waiting list currently contains 103 patients with a mean BMI of 53 kg/m2 and 250 new referrals are on a waiting list for initial review. CONCLUSION: A banding service for the public is a unique experience. The BMI is greater than in other published series; diverse geographic origin of the patients creates difficulties with review and there are limited surgical resources. The Royal Brisbane and Women's Hospital is leading the way towards a multidisciplinary clinic approach to managing obesity. However, more resources will be required to have an effect on overall public health.

Reducing complications with improving gastric band design.

BACKGROUND: Adjustable gastric bands have undergone significant design changes since their introduction. Band diameter, balloon volume, and shape have been modified to create high balloon fill volumes but lower and more evenly distributed pressure on the upper stomach. There have been few comparative studies on complication rates with different band types. OBJECTIVES: To compare complication rates among different types of adjustable gastric bands at a single institution. SETTING: University-affiliated hospital, United States. METHODS: We performed a retrospective cohort study of adult patients with a body mass index ≥ 35.0 kg/m(2) who underwent laparoscopic adjustable gastric banding from January 1, 2001 to December 31, 2007 and were followed for at least 5 years. Primary outcomes of the analysis were complications requiring operative management at our institution within the first 5 years after initial band placement. Reoperative procedures included diagnostic laparoscopy, hiatal hernia repair, band repositioning, replacing the band, removing the band, and converting to another bariatric procedure. RESULTS: For this study, 2711 patients met the inclusion criteria-1827 (67.4%) women and 884 (32.6%) men. Bands initially implanted included first-generation bands, LAP-BAND™ 9.75 cm (24.0%), 10 cm (33.9%) and Vanguard (24.8%) and second-generation bands, AP standard (9.5%) and AP large (7.9%). Four hundred and eighty-five patients experienced complications requiring reoperation. The 5-year follow-up rate was 63.3%. In the first 5 postoperative years there were significantly fewer complications with second-generation bands (10.0% versus 19.5%, P<.0001). Smaller, older bands had the highest complication rates (LAP-BAND 9.75 cm, 28.2%) and complication rates decreased with each successive model. Rates of band removal were not different between first- and second-generation bands. The rate of multiple complications was low at 1.5%. CONCLUSION: First-generation bands are associated with higher complication rates. Our study found that complication rates decreased with each successive model. We can expect that future design modifications will continue improve the performance with the adjustable gastric band.

Weight loss outcomes among patients referred after primary bariatric procedure.

BACKGROUND: Bariatric patients may not always obtain long-term care by their primary surgeon. Our aim was to evaluate weight loss outcomes in patients who had surgery elsewhere. METHODS: We conducted a retrospective analysis. Postreferral management included nonsurgical, revision, or conversion. Primary outcomes were percent excess weight loss (%EWL) overall, according to original operation, and based on postreferral management. RESULTS: Between 2001 and 2013, there were 569 patients. Mean follow-up was 3.1 years. Management was 42% nonsurgical, 41% revision, and 17% conversion. Overall, mean %EWL was 45.3%. Based on original surgery type, %EWL was 41.2% for adjustable gastric banding vs 58.3% for Roux-en-Y gastric bypass (P ≤ .0001). Management affected %EWL (41.2% nonsurgical vs 45.3% revision vs 55.1% conversion, P ≤ .0001). CONCLUSIONS: Patients referred after bariatric surgery can achieve satisfactory weight loss. This differs based on surgery type and management strategy.

Long-term outcomes after Roux-en-Y gastric bypass: 10- to 13-year data.

BACKGROUND: Short- and mid-term data on Roux-en-Y gastric bypass (RYGB) indicate sustained weight loss and improvement in co-morbidities. Few long-term studies exist, some of which are outdated, based on open procedures or different techniques. OBJECTIVES: To investigate long-term weight loss, co-morbidity remission, nutritional status, and complication rates among patients undergoing RYGB. SETTING: An academic, university hospital in the United States. METHODS: Between October 2000 and January 2004, patients who underwent RYGB≥10 years before study onset were eligible for chart review, office visits, and telephone interviews. Revisional surgery was an endpoint, ceasing eligibility for study follow-up. Outcomes included weight loss measures and rates of co-morbidity remission, complications, and nutritional deficiencies. RESULTS: RYGB was performed in 328 patients with a mean preoperative body mass index of 47.5 kg/m(2). Of 294 eligible patients, 134 (46%) were contacted for follow-up at ≥ 10 years (10+Year follow-up). Mean percentage excess weight loss (%EWL) was 58.9% at 10+Year. Higher %EWL was achieved by non-super-obese versus super-obese (61.3% versus 52.9%, P = .034). Blood pressure, lipid panel, and hemoglobin A1c improved significantly. At 10 years, remission of co-morbidities was 46% for hypertension and hyperlipidemia and 58% for diabetes mellitus. Thirty patients (9%) had revisional surgery for weight regain. Sixty-four patients (19.5%) had long-term complications requiring surgery. All-cause mortality was 2.7%. Nutritional deficiencies were seen in 87% of patients. CONCLUSIONS: Weight loss after RYGB appears to be significant and sustainable, especially in the non-super-obese. Co-morbidities are improved, with a substantial number in remission a decade later. Nutritional deficiencies are almost universal.