HFE genotype, parenchymal iron accumulation, and liver fibrosis in patients with nonalcoholic fatty liver disease.

BACKGROUND & AIMS: Mutations in the hemochromatosis gene (HFE) (C282Y and H63D) lead to parenchymal iron accumulation, hemochromatosis, and liver damage. We investigated whether these factors also contribute to the progression of fibrosis in patients with nonalcoholic fatty liver disease (NAFLD). METHODS: We studied clinical, histologic (liver biopsy samples for hepatocellular iron accumulation), serologic (iron and enzyme levels), and genetic (HFE genotype) data from 587 patients from Italy with NAFLD and 184 control subjects. RESULTS: Iron accumulation predominantly in hepatocyes was associated with a 1.7-fold higher risk of a fibrosis stage greater than 1 (95% confidence interval [CI]: 1.2-2.3), compared with the absence of siderosis (after adjustment for age, body mass index, glucose tolerance status, and alanine aminotransferase level). Nonparenchymal/mixed siderosis was not associated with moderate/severe fibrosis (odds ratio, 0.72; 95% CI: 0.50-1.01). Hepatocellular siderosis was more prevalent in patients with HFE mutations than in those without; approximately one third of patients with HFE mutations had parenchymal iron accumulation (range, 29.8%-35.7%, depending on HFE genotype). Predominantly hepatocellular iron accumulation occurred in 52.7% of cases of patients with HFE mutations. There was no significant association between either the presence of HFE mutations or specific HFE genotypes and the severity of liver fibrosis. CONCLUSIONS: Iron deposition predominantly in hepatocyes is associated with more severe liver damage in patients with NAFLD. However, HFE mutations cannot be used to identify patients with hepatocellular iron accumulation.

Treatment of band erosion: feasibility and safety of endoscopic band removal.

BACKGROUND: Band erosion is reported with a highly variable incidence (0.3-14%) after laparoscopic adjustable gastric banding. Removal of the band is mandatory because the patient regains weight and may become symptomatic, but no consensus exists about the best method, surgical or endoscopic, for this purpose. This study aimed to evaluate the feasibility and effectiveness of endoscopic management of band erosion. METHODS: In this study, 23 patients were treated for band erosion after gastric banding: 8 from the authors' series of 951 patients (incidence, 0.84%) and 15 referred to the authors' surgical department from other hospitals. The endoscopic method of band removal was used in 20 cases. Because of complications associated with erosion, three patients were submitted instead to laparoscopic removal. RESULTS: Endoscopic removal of the band was successful for 16 of 20 patients. Four cases required conversion of the procedure to surgery: in one case due to complications with the endoscopic cutting wire and in the three remaining cases due to dense perigastric adhesions blocking the band. The follow-up evaluation of the patients who had the endoscopic removal was uneventful, with quick discharge at resumption of oral feeding. The patients who underwent laparoscopic removal had a longer hospital stay, and one patient had a leak from the anterior gastrotomy. CONCLUSIONS: Despite a few complications, endoscopic removal seems to be the procedure of choice for the treatment of band erosion. It allows quick resumption of oral feeding and rapid discharge of patients and appears to be safer and more effective than laparoscopic removal. Conversion to surgery is unlikely but possible. Therefore, the authors always recommend that the procedure be performed in the operating room.

Laparoscopic adjustable gastric banding via pars flaccida versus perigastric positioning: technique, complications, and results in 2,549 patients.

AIM: Retrospective multicenter analysis of the results of two different approaches for band positioning: perigastric and pars flaccida. METHODS: Data were collected from the database of the Italian Group for LapBand (GILB). Patients operated from January 2001 to December 2004 were selected according to criteria of case-control studies to compare two different band positioning techniques: perigastric (PG group) and pars flaccida (PF group). Demographics, laparotomic conversion, postoperative complications, and weight loss parameters were considered. Data are expressed as mean +/- standard deviation. RESULTS: 2,549 patients underwent the LapBand System procedure [age: 40 +/- 11.7 years; sex: 2,130 female, 419 male; body mass index (BMI): 46.4 +/- 6.9 kg/m(2); excess weight (EW): 60.1 +/- 23.6 kg; %EW: 90.1 +/- 32.4]. During this period 1,343/2,549 (52.7%) were operated via the pars flaccida (PF group) and 1,206/2,549 (47.3%) via the perigastric approach (PG group). Demographics for both groups were similar. Thirty-day mortality was absent in both groups. Operative time was significantly longer in the PG group (80 +/- 20 min versus 60 +/- 40 min; p < 0.05). Hospital stay was similar in the two groups (2 +/- 2 days). Laparotomic conversion was significantly higher in the PG group (6 versus 2 patients; p < 0.001). Overall postoperative complication rate was 172/2,549 (6.7%) and was linked to gastric pouch dilation/slippage (67/172), intragastric migration/erosion (17/172), and tube/port failure (88/172). Gastric pouch dilation and intragastric migration were significantly more frequent in the PG group: 47 versus 20 (p < 0.001) and 12 versus 5 (p < 0.001), respectively. Patients eligible for minimum 3-year follow-up were 1,118/1,206 (PG group) and 1,079/1,343 (PF group). Mean BMI was 33.8 +/- 12.1 kg/m(2) (PG group) and 32.4 +/- 11.7 kg/m(2) (PF group) (p = ns), and mean percentage excess weight loss (%EWL) was 47.2 +/- 25.4 and 48.9 +/- 13.2 in PG and PF groups, respectively (p = ns). CONCLUSIONS: Significant improvement in LapBand System results with regard to laparotomic conversion and postoperative complication rate, with similar weight loss results, was observed in the pars flaccida group.

Concurrent band and tube migration following acute pancreatitis.

A 52-year-old woman developed an acute pancreatitis 7 years after gastric banding for morbid obesity. The patient presented a stable weight loss. Three months before, a radiological band calibration showed a normal position of the band. Investigations revealed that the pancreatitis was related to the presence of gallstones, complicated by a stone in the choledocic tract. The band migrated completely into the gastric lumen and passed far down the jejunum. The band was still connected to the port but the connecting tube did not follow the normal course of duodenum, entering the stomach in the middle of the greater curvature and getting out on the same side 5 cm more distad. The patient underwent first an endoscopic retrograde cholangiopancreatogram with sphinterectomy, then a laparoscopy that allowed us to remove the band, via jejunotomy, and the tube, which was outside the stomach. The postoperative course was uneventful.

Laparoscopic Gastric Bypass with Fundectomy and Gastric Remnant Exploration (LRYGBfse): Results at 5-Year Follow-up.

BACKGROUND: The laparoscopic Roux-en-Y gastric bypass (LRYGB) is the gold standard treatment for morbid obesity. After LRYGB, the endoscopic access to the gastric remnant and pancreaticobiliary system is challenging. The laparoscopic gastric bypass with fundectomy and exploration of the gastric remnant (LRYGBfse) was introduced in an attempt to overcome this limitation. The purpose of this study was to analyze the medium-term outcomes and safety of LRYGBfse. METHODS: Observational prospective single-arm multicenter cohort study. Patients with BMI > 35 kg/m2 were included. Previous open abdominal surgery was an exclusion criterion. Postoperative 1, 2, 3, and 5-year weight loss, BMI decrease, and percentage of excess weight loss (%EWL) were recorded. Wilcoxon signed rank sum test was used for paired data. RESULTS: Among 653 enrolled patients, 229 completed the 5-year follow-up. Preoperative median body weight (kg) and BMI (kg/m2) were 133.4 kg (interquartile range (IQR) = 12.0) and 48.2 kg/m2 (IQR = 10.1), respectively. Median 5-year body weight, BMI, and %EWL were 83.7 (IQR = 17.3), 31.2 (IQR = 7.7), and 74.8 (IQR = 23.4), respectively, all significantly improved compared to baseline (p = 0.002, p = 0.001, and p = 0.012, respectively). Comorbid improvement or resolution was observed in 88% of the patients. No major intraoperative complications were reported. Postoperative overall morbidity and mortality rates were 1 and 0%, respectively. Banding removal was necessary in one patient 62 months after the index operation. CONCLUSIONS: The LRYGBfse seems safe and effective with durable results at 5-year follow-up. Endoscopic exploration of the gastric remnant is an additional valuable tool.

Band erosion following gastric banding: how to treat it.

BACKGROUND: Intragastric band migration is an unusual but major long-term complication of gastric banding: its frequency ranges from 0.5-3.8% and always requires removal of the band. Different laparoscopic, laparotomic or endoscopic methods are currently used for band removal. METHODS: 571 morbidly obese patients underwent adjustable gastric banding from February 1998 to July 2006. Band erosion occurred in 3 patients (0.52%). In addition, 6 such patients were referred to our Department from other hospitals. To remove the migrated band, in most patients we used an endoscopic approach with a device designed to cut the band: the Gastric Band Cutter (AMI, Agency for Medical Innovation). RESULTS: In 7 of the 9 patients, we used the gastric band cutter to remove the band endoscopically. It was able to cut the band successfully in all cases except one, where twisting of the cutting wire required conversion from endoscopy to laparoscopy. In another case, the band, after being cut, was locked in the gastric wall and required laparotomic removal. In 2 patients, we had to remove the band surgically - in one case for port-site infection with subphrenic abscess, and in the other case for complete band migration into the jejunum associated with acute pancreatitis, cholelithiasis and choledocholithiasis. CONCLUSION: The Gastric Band Cutter, when used, was successful in dividing the band in all cases except one, although we could not always complete the procedure endoscopically. Endoscopic removal seems to be the procedure of choice for band erosion, because it allows earlier patient discharge and avoids a surgical operation. It is advisable to perform the endoscopic removal in the operating theater, because of possible complications of the procedure.

The bilio-intestinal bypass.

BACKGROUND: Since 1990 we adopted the bilio-intestinal bypass (BIBP) for all morbid obese patients eligible to a malabsorption procedure. Since 2001 we used laparoscopic technique. MATERIALS AND METHODS: 102 patients; mean age 35.4 (18-54) years; preoperative mean weight Kg 148.3 (105-225); mean preoperative BMI 54.1 kg/m2 (40-66.2); mean follow-up 10 years (1-22). 83 patients underwent open and 19 laparoscopic BIBP. The operation was performed with five lap ports. Section of the jejunum 30 cm from the Treitz and of mesentery was made by linear stapler. The cholecysto-jejunal anastomosis was completed with 45 mm linear stapler. A side-to-side anastomosis between the proximal jejunum and the last 12-18 cm of the ileum was created by firing a 60 mm linear stapler. On the excluded ileum an anti-reflux valve system was hand-sutured. RESULTS: Five years post-operatively mean weight was 89 (62-130) kg, mean BMI was 31 (24-41) kg/m2. Two patients of the 19 laparoscopic patients were converted in open surgery for adhesions post-appendectomy. The main late complications were incisional hernia (19.3%) and abdominal bloating (2.9%). The reversal and conversion rate was 65%. There was no death. CONCLUSION: Our experience showed that five years post-BIBP the weight loss was satisfactory in 90.7% of patients. Using laparoscopic technique it is possible to reduce pain, in-hospital time, respiratory and thromboembolic complications, convalescence and incisional hernia.

Histologic study of tissue reaction to the gastric band: does it contribute to the problem of band erosion?

BACKGROUND: One of the major complications of gastric banding is intragastric migration of the band. The frequency ranges from 0.5% to 3.8%, and removal of the band is always required. We undertook a prospective study with the aim to determine the reasons for this significant complication in bariatric surgery. METHODS: 480 morbidly obese patients underwent adjustable gastric banding in our Surgical Department, from February 1998 to October 2005. 31 of them were reoperated for different surgical problems, at an average time of 39 months after the bariatric procedure. During the reoperation, some fragments of fibro-adipose tissue in close contact with the band were removed. They were examined, focusing on the following parameters: acute and chronic inflammation, fibrosclerosis, and foreign body granulomatous reaction. RESULTS: Histological assessment showed the presence of acute and chronic inflammation, generally of mild and medium grade; fibrosclerosis was present mostly in a severe form, indicating a biological periprosthesic wall that separates and protects the gastric wall from the band; no cases of foreign body reaction were observed, nor were silicone inclusions found inside the inflammatory cells. CONCLUSION: The histologic changes of periprosthesic tissue do not appear to account for endoluminal migration of the gastric band. Thus, band erosion could have a closer correlation with other causes, such as infection of the band or intraoperative surgical damage, possibly due to direct mechanical action or to the thermal effect of the electric scalpel.

Prevention of pouch dilatation after laparoscopic adjustable gastric banding.

BACKGROUND: The major long-term complication of laparoscopic adjustable gastric banding (LAGB) is dilatation of the gastric pouch, that is reported with a frequency ranging from 1 to 25%, and often requires removal of the band. In addition to the usual recommendations of bariatric surgery centers and dietetic advice to prevent this complication, over the last 4 years we introduced a technical modification of the procedure. METHODS: From Nov 1993 to Dec 2004, 684 morbidly obese patients underwent adjustable gastric banding, 83 patients by open surgery and 601 patients by laparoscopy. The first 323 patients (group A) were operated by the perigastric approach, and 57 patients (group B) were operated by the pars flaccida approach. Since Dec 2000, 304 patients (group C) were operated with a modified pars flaccida technique, which consisted in suturing the gastric lesser curvature below the band with one or two stitches to the right phrenic crus to secure the band in place. RESULTS: In group A, the most important late complication was irreversible dilatation of the gastric pouch, which occurred in 35 patients (10.8%), and required removal of the band in 30 cases and replacement in 5. In group B, there were 3 pouch dilatations (5.2%). In group C, only 4 dilatations occurred (1.31%), which required 3 band removals and 1 band replacement. CONCLUSION: Dilatation of the gastric pouch appears to be dramatically reduced by our minor technical modification of band placement.

Adjustable gastric banding for morbid obesity. Our experience.

BACKGROUND: The adjustable gastric banding is considered the most common procedure in Europe for the treatment of morbid obesity. We report our experience with this procedure, that was introduced in our Departments of Surgery since 1993. METHODS: From December 1993 to December 2004, 684 morbid obese patients (139 males and 545 females) underwent adjustable gastric banding (AGB) in our departments of Surgery. The first 323 patients were operated with perigastric procedure, the following 361 patients with pars flaccida technique. 601 patients were operated with laparoscopic approach, 83 with open approach. The average follow-up is 5 years. RESULTS: Mean BMI decreased from 42.2 to 34 Kg/m2 five years after the operation, with an EWL of 54 %. The main early complications were: intraoperative gastric perforation (5 patients, 1 of which repaired in laparoscopy); hemorrhage from short gastric vessels (3 patient, repaired in laparotomy). The major late complications were: intragastric band migration (7 patients); irreversible dilatation of the gastric pouch (42 patients, treated surgically with band removal or repositioning). CONCLUSION: In our experience laparoscopic adjustable gastric banding is a safe and effective procedure, suitable to most patients, and should be considered as the first choice in the surgical treatment of morbid obesity.

[Psychiatric features before and after intervention: a study of patients affected by severe obesity undergoing adjustable gastric banding]. / Tratti psichiatrici pre- e post-intervento: studio di un campione di pazienti affetti da grave obesità sottoposti a bendaggio gastrico regolabile.

AIM: This study identifies psychological features and the evolution of psychiatric symptoms in a group of patients affected by obesity, who underwent adjustable gastric banding. MATERIALS AND METHODS: In this group, other than clinical visit, test SCL-90 is made in preoperative time. In postoperative SCL-90, TAS and BES were carried out. Patients evaluated before and after bariatric surgery were 220 and 115, respectively. SCL-90 test made before bariatric surgery showed high values (>0.7) for cluster related to somatization, interpersonal sensitivity, paranoid ideation, depression and obsessive compulsive disorder. DISCUSSION: Depression symptoms were more important in patients undergoing endogastric balloon placement (mean value of 0.9). Anxious symptoms showed a mean value of 0.73 in patients undergoing endogastric balloon placement as compared to a mean value of 0.52 in patients undergoing gastric banding. CONCLUSIONS: Our findings show that in patients undergoing bariatric surgery, depressive symptoms are more common preoperatively and normalize at follow-up. This confirms that a possible cause of depression is obesity. The present study also shows that anxious symptoms are lower in obese patients.

Injection port and connecting tube complications after laparoscopic adjustable gastric banding.

BACKGROUND: Port-site and connecting tube complications are usually considered minor problems in the follow-up of obese patients submitted to laparoscopic adjustable gastric banding (LAGB), but the incidence reported in literature ranges from 4.3% to 24%. These complications are mainly because of the mechanical stress of the port and the tube; therefore, their incidence might be time dependent and probably increase during the follow-up. METHODS: We evaluated retrospectively 489 obese patients submitted to LAGB from February 1998 to December 2005, considering all the complications of the connecting tube and port. Their clinical signs, imaging exams, operative reports, and hospitalization files were evaluated. RESULTS: The mean follow-up of the patients was 41 months. Seventy-one patients (14.5%) presented port and connecting tube complications that required 82 revisional operations. Fifty-four patients had system leaks, 3 had infection problems, and 14 mechanical problems, always requiring surgical revision. In five patients, the system leak was observed twice and required a second surgical repair, while one patient presented three times a leakage of the connecting tube and needed three surgical revisions. All cases of system leakage were related to significant weight regain. In one case of recurrent port infection, we had to remove the band. CONCLUSION: Port-site and connecting tube problems are the most common complications after LAGB. Although they are considered marginal complications, they usually cause weight regain; their correction often requires surgical revision and sometimes removal of the band.

Failure of gastric bypass following several gastrointestinal hemorrhages.

Gastrointestinal hemorrhage is an infrequent major complication of gastric bypass. We present a 22-year-old morbidly obese man who underwent a laparoscopic Roux-en-Y gastric bypass and had several life-threatening hemorrhages from both the gastric pouch and gastric remnant, associated with an intra-abdominal hemorrhage. The patient underwent two subsequent reoperations, leading eventually to gastrectomy. The possibility to discover all the sources of bleeding after gastric bypass is discussed, and the adoption of a modification of the procedure that allows the investigation of the excluded stomach is suggested.

Effects of the beach chair position, positive end-expiratory pressure, and pneumoperitoneum on respiratory function in morbidly obese patients during anesthesia and paralysis.

BACKGROUND: The authors studied the effects of the beach chair (BC) position, 10 cm H2O positive end-expiratory pressure (PEEP), and pneumoperitoneum on respiratory function in morbidly obese patients undergoing laparoscopic gastric banding. METHODS: The authors studied 20 patients (body mass index 42 +/- 5 kg/m2) during the supine and BC positions, before and after pneumoperitoneum was instituted (13.6 +/- 1.2 mmHg). PEEP was applied during each combination of position and pneumoperitoneum. The authors measured elastance (E,rs) of the respiratory system, end-expiratory lung volume (helium technique), and arterial oxygen tension. Pressure-volume curves were also taken (occlusion technique). Patients were paralyzed during total intravenous anesthesia. Tidal volume (10.5 +/- 1 ml/kg ideal body weight) and respiratory rate (11 +/- 1 breaths/min) were kept constant throughout. RESULTS: In the supine position, respiratory function was abnormal: E,rs was 21.71 +/- 5.26 cm H2O/l, and end-expiratory lung volume was 0.46 +/- 0.1 l. Both the BC position and PEEP improved E,rs (P < 0.01). End-expiratory lung volume almost doubled (0.83 +/- 0.3 and 0.85 +/- 0.3 l, BC and PEEP, respectively; P < 0.01 vs. supine zero end-expiratory pressure), with no evidence of lung recruitment (0.04 +/- 0.1 l in the supine and 0.07 +/- 0.2 in the BC position). PEEP was associated with higher airway pressures than the BC position (22.1 +/- 2.01 vs. 13.8 +/- 1.8 cm H2O; P < 0.01). Pneumoperitoneum further worsened E,rs (31.59 +/- 6.73; P < 0.01) and end-expiratory lung volume (0.35 +/- 0.1 l; P < 0.01). Changes of lung volume correlated with changes of oxygenation (linear regression, R2 = 0.524, P < 0.001) so that during pneumoperitoneum, only the combination of the BC position and PEEP improved oxygenation. CONCLUSIONS: The BC position and PEEP counteracted the major derangements of respiratory function produced by anesthesia and paralysis. During pneumoperitoneum, only the combination of the two maneuvers improved oxygenation.