Quality of life after sleeve gastrectomy and adjustable gastric banding.

BACKGROUND: With the addition of laparoscopic vertical sleeve gastrectomy (SG) to the bariatric surgery procedural toolkit, patients desiring a restrictive bariatric procedure often choose between adjustable gastric banding (LAGB) and SG. One study compared quality of life after these 2 procedures and found no difference. The purpose of our study was to re-evaluate the postoperative quality of life in LAGB and SG patients at a military teaching hospital in the United States. METHODS: A retrospective review of 108 consecutive laparoscopic restrictive bariatric procedures performed within 15 months at a Department of Defense hospital was conducted. Of these 108 patients, 69 had undergone laparoscopic vertical SG and 39 LAGB. A validated quality of life questionnaire (Bariatric Quality of Life) was conducted a mean of 9.3 ± 3.2 months (range 5-16) postoperatively. The weight loss and standard laboratory parameters were measured at 0, 1, 3, 6, and 12 months. RESULTS: The quality of life assessment revealed significantly better scores after SG than after LAGB (66.5 versus 57.9, P = .0002). The excess weight loss and excess body mass index loss at 3, 6, and 12 months postoperatively were significantly greater in the laparoscopic SG group. The patients demonstrated a clear preference over time for SG once it was offered. CONCLUSION: Early postoperative quality of life was superior after SG than after LAGB. SG also resulted in superior early excess weight loss. In a practice not constrained by reimbursement, these findings were associated with increased patient choice of SG after it began to be offered.

Management options for symptomatic stenosis after laparoscopic vertical sleeve gastrectomy in the morbidly obese.

BACKGROUND: This study aimed to determine the incidence, etiology, and management options for symptomatic stenosis (SS) after laparoscopic sleeve gastrectomy (LSG). METHODS: A retrospective study reviewed morbidly obese patients who underwent LSG between October 2008 and December 2010 to identify patients treated for SS. RESULTS: In this study, 230 patients (83% female) with a mean age of 49.5 years and a mean body mass index (BMI) of 43 kg/m(2) underwent LSG. In 3.5% of these patients (100% female; mean age, 42 years; mean BMI, 42.6 kg/m(2)), SS developed. The LSG procedure was performed using a 36-Fr. bougie and tissue-reinforced staplers. Four patients had segmental staple-line imbrication, and seven patients underwent contrast study, with 71.4% demonstrating a fixed narrowing. Endoscopy confirmed short-segment stenoses: seven located at mid-body and one located near the gastroesophageal junction. Endoscopic management was 100% successful. The mean number of dilations was 1.6, and the median balloon size was 15 mm. The mean time from surgery to initial endoscopic intervention was 48.8 days, and the mean time from the first dilation to toleration of a solid diet was 49.6 days. Two patients were referred to our institution after undergoing LSG at another facility. The mean time to the transfer was 28.5 days. The two patients had a mean age of 35 years and a mean BMI of 42.3 kg/m(2). Both patients experienced immediate SS after perioperative complications comprising one staple-line hematoma and one leak. Contrast studies demonstrated minimal passage of contrast through a long-segment stenosis. Both patients underwent multiple endoscopic dilation procedures and endoluminal stenting, ultimately requiring laparoscopic conversion to Roux-en-Y gastric bypass. The mean time from the initial surgery to the surgical revision was 77 days, and the mean time after the first intervention to tolerance of a solid diet was 82 days. CONCLUSION: Symptomatic short-segment stenoses after LSG may be treated successfully with endoscopic balloon dilation. Long-segment stenoses that do not respond to endoscopic techniques may ultimately require conversion to Roux-en-Y gastric bypass.

Integrated bioabsorbable tissue reinforcement in laparoscopic sleeve gastrectomy.

Division of the stomach in laparoscopic sleeve gastrectomy may be performed using bare stapler cartridges or cartridges fitted with tissue reinforcement strips, with or without oversewing. Many tissue reinforcement strips are after-market add-on products that must be fitted onto a stapler during surgery. A retrospective review was conducted of 85 consecutive patients undergoing laparoscopic sleeve gastrectomy using a novel integrated bioabsorbable polymer buttress pre-mounted on a single-use loading unit stapler. Mean preoperative body mass index (BMI) was 41.7 ± 5.2 kg/m(2). Morbidity and short-term outcomes were documented. Mean follow-up was 8.1 ± 3.6 months (range, 1.0-16.2 months). There were no mortalities or staple line leaks noted in this series with short-term follow up. The major complication rate (grade III and above) was 7.1% and included: reoperation for staple line bleeding (2.4%, n = 2), gastric sleeve stenosis requiring balloon dilation (2.4%, n = 2), choledocholithiasis 2 weeks after surgery (1.2%, n = 1), and reoperation without abnormality for suspected perioperative obstruction (1.2%, n = 1). Mean percent excess BMI loss at 3 (44.6 ± 11.3), 6 (57.9 ± 17.2), and 12 months (72.4 ± 27.5) was comparable to other published series. The use of an integrated absorbable synthetic polymer for stapled tissue reinforcement in laparoscopic sleeve gastrectomy appears to be feasible and safe, and yields results consistent with other published techniques.

Preoperative weight gain does not predict failure of weight loss or co-morbidity resolution of laparoscopic Roux-en-Y gastric bypass for morbid obesity.

BACKGROUND: Success with preoperative weight loss (PWL) is often mandated by the bariatric team to assess patient compliance and has been suggested to correlate with improved postoperative weight loss outcomes. METHODS: We performed a retrospective analysis of 1629 consecutive patients undergoing laparoscopic Roux-en-Y gastric bypass at Duke University Medical Center. Patients with a preoperative weight gain (PWG) or loss of > or =10 lb were compared. Patients with <12 months of follow-up were excluded. RESULTS: We found no difference between the 2 groups (PWG, n = 115, PWL, n = 88) with regard to age, gender, race, preoperative body mass index, presence of co-morbidities, or interval between the initial program-entry weight and surgery (149 versus 141 d). No difference was found in the percentage of excess weight loss (EWL) at 12 months, when calculated using the patient's immediate preoperative weight (PWG group, 63.5% EWL versus PWL group, 63.9% EWL, P = NS). If the %EWL was calculated using the initial program-entry weight, the PWL did confer a transient postoperative weight loss advantage; however, this did not persist past 24 months postoperatively. At both 12 and 24 months, the resolution rates of diabetes (82% versus 83% at 2 yr; P = NS), hypertension (48% versus 42% at 2 yr, P = NS), and continuous positive airway pressure discontinuation (87% versus 87% at 1 yr, P = NS) were equivalent. No differences in perioperative complications or conversion rates were detected. The operative time was slightly longer for the PWG group (119.7 versus 104.9 min, P = .02). CONCLUSION: The results of our study have shown that weight loss before laparoscopic Roux-en-Y gastric bypass is not mandatory and might deter patients from considering weight loss surgery. Laparoscopic Roux-en-Y gastric bypass can be performed safely with equivalent co-morbidity resolution and %EWL regardless of PWG or PWL.