Oncological Outcome After Laparoscopic 'No-touch' RAMPS Versus 'Touch' Left Pancreatectomy for Pancreatic Adenocarcinoma.

BACKGROUND/AIM: The validity of laparoscopic distal pancreatectomy in left-sided pancreatic adenocarcinoma (PDAC) is still unclear. However, a meticulous surgical dissection through a "no-touch" technique might allow a radical oncological resection with minimal risk of tumor dissemination and seeding. This study aimed to evaluate the oncological outcomes of the laparoscopic "no touch" technique versus the "touch" technique. PATIENTS AND METHODS: From 2001 to 2020, we retrospectively analyzed 45 patients undergoing laparoscopic distal pancreatectomy (LDP) for PDAC in two centers. Factors associated with overall (OS), disease-free survival (DFS) and time to recurrence (TTR) were identified. RESULTS: The OS rates in the 'no-touch' and 'touch' groups were 95% vs. 78% (1-year OS); 50% vs. 50% (3-year OS), respectively (p=0.60). The DFS rates in the 'no-touch' and 'touch' groups were 72 % vs. 57% (1-year DFS); 32% vs. 28% (3-year DFS), respectively (p=0.11). The TTR rates in the 'no-touch' and 'touch' groups were 77% vs. 61% (1-year TTR); 54% vs. 30% (3-year TTR); 46% vs. 11% (5-year TTR); respectively (p=0.02) In multivariate analysis the only factors were Touch technique [odds ratio (OR)=2.62, p=0.02] and lymphovascular emboli (OR=4.8; p=0.002). CONCLUSION: We advise the 'no-touch' technique in patients with resectable PDAC in the pancreatic body and tail. Although this study does not provide definitive proof of superiority, no apparent downsides are present for the 'no-touch' technique in this setting although there could be oncological benefits.

Ketamine as a component of multimodal analgesia for pain management in bariatric surgery: A systematic review and meta-analysis of randomized controlled trials.

Introduction: Anaesthesia in morbidly obese people is challenging with a high dose of opioid consumption. This systematic review and meta-analysis of randomised controlled trials (RCTs) summaries evidence comparing ketamine to placebo for pain management after bariatric surgery. Methods: We used PRISMA 2020 and AMSTAR 2 guidelines to conduct this study. The random-effects model was adopted using Review Manager Version 5.3 for pooled estimates. Results: Seven RCTs published between 2009 and 2021 were eligible, including a total of 412 patients (202 patients in the ketamine group and 210 patients in the control group). In the ketamine group total opioid consumption during the first 24 h postoperatively was reduced (mean difference, MD = -5.89; 95% CI [-10.39, -1.38], p = 0.01), lower pain score at 4 h (MD = -0.81; 95% CI [-1.52, -0.10], p = 0.03), pain score at 8 h (MD = -1.00; 95% CI [-1.21, -0.79], p < 0.01), and shorter hospital stay (MD = -0.10; 95% CI [-0.20, -0.01], p = 0.03). There was no significant difference between the two groups regarding duration of anaesthesia (MD = -3.42; 95% CI [-8.62, 1.82], p = 0.20), or sedation score (MD = -0.02; 95% CI [-0.21, 0.17], p = 0.84). As concern the postoperative complications, risks of postoperative nausea and vomiting(OR = 0.75; 95% CI [0.27, 2.04], p = 0.56), hallucinations (OR = 5.47; 95% CI [0.26, 117.23], p = 0.28), dizziness (OR = 1.05; 95% CI [0.14, 7.78], p = 0.96), and euphoria (OR = 5.77; 95% CI [0.65, 51.52], p = 0.12) were not different between the two groups either. Conclusion: Ketamine could be an effective and safe technique for pain management following bariatric surgery. It reduces opioid consumption, postoperative pain, and hospital stay.RegistrationThis review was registered in PROSPERO (CRD42022296484).

Quality of oncological resection criteria in minimally invasive esophagectomy.

BACKGROUND: Even though minimally invasive esophageal surgery (MIE) is spreading, questions remain regarding its oncological outcomes. The aim of this study was to assess the quality of oncological resection criteria in MIE. METHODS: All patients undergoing a two-way Ivor Lewis esophagectomy for esophageal or junctional cancer between 2010 and 2020 in a single tertiary upper gastrointestinal surgery ward were analyzed retrospectively. The following oncological criteria were analyzed: lymph node (LN) harvest and location, positive lymph node rate, margins, and R0 rates. They were compared between the MIE group (thoracoscopy + laparoscopy) and the hybrid group (H/O, thoracotomy + laparoscopy). RESULTS: Among the 240 patients included, 34 (14%) had MIE and 206 a hybrid esophagectomy. Main surgical indication was lower thoracic adenocarcinoma and the rate of neoadjuvant treatments administered (chemotherapy or chemoradiotherapy) was comparable between both groups (p = 1.0). LN harvest was significantly higher in the MIE group (31 ± 9 vs. 28 ± 9, p = 0.04) as well as thoracic LN harvest (14 ± 7 vs. 11 ± 5, p = 0.002). When analyzing patients according to T stage and response to neoadjuvant treatments, patients with T1 and T2 tumors and patients with a poor pathological response (TRG3, 4, 5) had a significantly higher LN harvest when undergoing a minimally invasive approach (p = 0.021 and p = 0.01, respectively). Positive LN rates (1.26 ± 3.63 in the MIE group vs. 1.60 ± 2.84 in the H/O group, p = 0.061), R0 rates (97% vs. 98.5%, p = 0.46) as well as proximal (p = 0.083), distal (p = 0.063), and lateral (p = 0.15) margins were comparable between both approaches. CONCLUSION: MIE seems oncologically safe and may even be better than the open approach in terms of LN harvest especially in patients with T1 and T2 tumors and in poor responders.

Anatomical Quality Criteria for Sleeve Gastrectomy.

BACKGROUND: Sleeve gastrectomy (SG) is the most common bariatric procedure performed worldwide. However, without a standardised surgical technique, heterogeneous outcomes and complications such as gastro-oesophageal reflux disease (GERD) have been reported. The aim of this study was to identify reproducible anatomical criteria for SG to obtain safe and effective results. METHODS: A prospective photographic study that captured every phase of each procedure was completed. The photographic documentation was carefully examined in order to identify anatomical criteria that would help make our technique reproducible. Postsurgical results were reported in terms of complications and mortality, while functional and morphological results were evaluated using 3-month upper gastrointestinal (UGI) series and 12-month computed tomography (CT) scan, respectively. BMI, percentage excess weight loss (%EWL), comorbidities, and GERD symptoms at 12 months were analysed. RESULTS: One hundred thirty-four consecutive laparoscopic SG were photographed, and four reproducible anatomical criteria were identified: (1) to preserve the gastric antral posterior ligament (GAPL); (2) to dissect the gastro-pancreatic ligament (GPL); (3) to expose the right edge of the left diaphragmatic crus; and (4) to ensure staple-line linearity. No leaks occurred, and only one patient needed relaparoscopy for staple-line hematoma. Mortality and 30-day readmission rates were null. Gastric tube morphologies on the 12-month CT scans were homogeneous. At 12 months, median BMI was 30.8 kg/m2 [IQR 20-47.2] and mean %EWL was 69.0 ± 24.5%; comorbidities resolved in 65.8-88.1% of patients, and GERD symptoms resolved in 44.4%. CONCLUSION: The four anatomical criteria for SG that we propose are safe, effective, and reproducible and have acceptable postsurgical outcomes.

Anastomotic Leakage After Laparoscopic Colectomy: Who Will Require Emergency Fecal Diversion?

Background: To identify predictive factors for reoperation because of anastomotic leakage (AL) after colectomy. Methods: Between 2007 and 2016, all patients who developed AL following right or left colectomy in an expert center were included. Patients who were treated surgically (all including fecal diversion) were compared with those who were managed conservatively. Results: Overall, 81 (6.5%) patients developed AL, of which 32 (39%) were managed nonoperatively and 49 (61%) required reoperation. On average, AL was diagnosed on postoperative day 4 (3-8) and mortality reached 4.9% (n = 4). Reoperation included anastomosis resection in 31 (67%) patients of which 26 (100%) had right colectomy and 5 (25%) left colectomy. Reoperation for AL was associated with increased intensive care management (P = .026) and deep abdominal collection (P = .002). T stage >2 and right-sided colectomy were the only independent risk factors associated with the need for reoperation for AL. Stoma reversal was performed in 42 (98%) patients after a median of 4 months. Conclusions: AL after colectomy is more likely to require reoperation with fecal diversion after right-sided colectomy and T > 2 colorectal cancer.

Safety and feasibility of repeat laparoscopic colorectal resection: a matched case-control study.

BACKGROUND: Perioperative outcomes of repeat laparoscopic colorectal resection (LCRR) have not been extensively reported. METHODS: Patients who underwent LCRR from 2010 to 2018 in an expert center were retrieved from a prospectively collected database and compared to 2:1 matched sample. Matching was based on demographics, surgical indication [colorectal cancer (CRC) or benign condition], and type of resection (right-sided resection or left-sided resection or proctectomy). RESULTS: Twenty-three patients underwent repeat LCRR with a median time of 36 months between the primary and the repeat LCRR. They were 12 (52%) men with a mean age of 64.9 years (31-87) and a median BMI of 21.4 kg/m2 (17.7-34). Indication for repeat LCRR was CRC, dysplasia, anastomotic stricture, and inflammatory bowel disease in 11 (48%), 5 (22%), 4 (17%), and 3 (13%) patients, respectively. A right-sided resection, a left-sided resection, and proctectomy were reported in 11 (48%), 8 (35%), and 4 (17%) patients, respectively. Median blood loss reached 211 mL (range 0-2000 mL). Thirteen (57%) patients required conversion to laparotomy including 12 for intense adhesions. The median length of hospital stay was 7.5 days (5-20). Two (9%) major complications (Clavien-Dindo ≥ 3) were reported: 1 (4%) anastomotic fistula and 1 (4%) postoperative hemorrhage, without mortality. Among patients who underwent repeat LCRR for CRC, histopathological examination showed R0 resection in all patients, with at least 12 lymph nodes harvested in ten (91%) patients. After matched case-control analysis that compared to primary LCRR, conversion rate (p = 0.03), operative time (p = 0.03), and intraoperative blood loss (p = 0.0016) were significantly increased in repeat LCRR, without impact on postoperative outcomes. CONCLUSIONS: Repeat LCRR seems to be feasible and safe in expert hands without compromising the oncologic outcomes. Intense postoperative adhesions and misidentification of blood supply might lead to conversion to laparotomy. Real benefits of laparoscopic approach for repeat LCRR should be assessed in further studies.

Limited Sensitivity of Circulating Tumor DNA Detection by Droplet Digital PCR in Non-Metastatic Operable Gastric Cancer Patients.

This study was designed to monitor circulating tumor DNA (ctDNA) levels during perioperative chemotherapy in patients with non-metastatic gastric adenocarcinoma. Plasma samples were prospectively collected in patients undergoing perioperative chemotherapy for non-metastatic gastric adenocarcinoma (excluding T1N0) prior to the initiation of perioperative chemotherapy, before and after surgery (NCT02220556). In each patient, mutations retrieved by targeted next-generation sequencing (NGS) on tumor samples were then tracked in circulating cell-free DNA from 4 mL of plasma by droplet digital PCR. Thirty-two patients with a diagnosis of non-metastatic gastric adenocarcinoma were included. A trackable mutation was identified in the tumor in 20 patients, seven of whom experienced relapse during follow-up. ctDNA was detectable in four patients (N = 4/19, sensitivity: 21%; 95% confidence interval CI = 8.5⁻43%, no baseline plasma sample was available for one patient), with a median allelic frequency (MAF) of 1.6% (range: 0.8⁻2.3%). No patient with available plasma samples (N = 0/18) had detectable ctDNA levels before surgery. After surgery, one of the 13 patients with available plasma samples had a detectable ctDNA level with a low allelic frequency (0.7%); this patient experienced a very short-term distant relapse only 3 months after surgery. No ctDNA was detected after surgery in the other four patients with available plasma samples who experienced a later relapse (median = 14.4, range: 9.3⁻26 months). ctDNA monitoring during preoperative chemotherapy and after surgery does not appear to be a useful tool in clinical practice for non-metastatic gastric cancer to predict the efficacy of chemotherapy and subsequent relapse, essentially due to the poor sensitivity of ctDNA detection.

Resection of an Esophageal Diverticulum by Thoracoscopy in Prone Position.

Diverticula of the middle one third of the esophagus are rare clinical entities, by comparison with the more common epiphrenic diverticula. For midesophageal diverticula, a minimally invasive approach has not been standardized. This report presents the case of a 60-year-old man with a large midesophageal diverticulum who was treated successfully by four-port video-assisted thoracic surgery while he was in the prone position. Thoracoscopy is a good approach for direct visualization of the diverticulum, and the prone position has several advantages to help clear the view. Routine myotomy for middle one-third diverticula is not advised, given the risk of poor functional results and diverticulization of the myotomy itself.

Enhanced recovery protocols in colonic surgery: retrospective cohort analysis of economic impact from an institutional point of view.

BACKGROUND: Despite increasing evidence supporting the beneficial effects of enhanced recovery protocols (ERPs), their accurate economic impact on institutions remains lacking. The aim of this study was to analyze ERP economic impact in a French center in order to further encourage implementation. METHODS: All patients who underwent elective laparoscopic right or left colectomy for benign or malignant pathology from 2014 to 2017 in a single center were retrospectively reviewed. ERP according to national recommendations was effective starting November 2015. Perioperative data and all direct costs borne by the institution were collected for each patient. Patients who underwent colectomy before and after ERP implementation were compared. RESULTS: Overall, 288 patients were included of which 144 received conventional perioperative care (CC) and 144 received ERP. There were 161 (56%) men, median age was 71 (28-92) years, and 242 (84%) patients underwent surgery for malignant disease. Operative time, intraoperative blood loss, and severe postoperative complications were similar between both groups. ERP was associated with reduced Clavien-Dindo I-II postoperative complications (15% vs. 28%, p = 0.010) and overall in-hospital stay (6 vs. 7 days, p = 0.003). Overall institutional costs were lower in the ERP group although difference was not statistically significant (7022 vs. 7501 euros, p = 0.098). Estimated savings per patient reached a mean of 480 euros. CONCLUSIONS: In a tertiary French center, ERP was associated with reduced postoperative morbidity and in-hospital stay resulting in considerable cost savings. Although not significant, ERP resulted in positive economic impact even in an early implementation phase.

Large gastrointestinal stromal tumours of the stomach: Is laparoscopy reasonable?

BACKGROUND: Laparoscopic resection (LR) offers significant advantages compared to open resections for gastric gastrointestinal stromal tumours (GISTs). We aimed to evaluate whether LR outcomes jeopardised short and long-term outcomes of patients with large GISTs. PATIENTS AND METHODS: Among 50 patients undergoing surgery for gastric GISTs, 12 underwent LR for large GISTs (>5 cm). Their characteristics, perioperative results and survival were retrospectively compared to those of 22 patients who underwent LR for 'small GIST'. RESULTS: The two groups were similar regarding demographics, rate of wedge resection and mean blood loss. No patient required transfusion or conversion. Operative time was significantly increased in the 'large GIST' group (160 min vs 112 min, P = 0.001). Mean tumour size was significantly lower in the 'small GIST' group (8.4 cm vs 2.4 cm, P = 0.0001). Resection margins were negative. The mortality rate was nil and the overall morbidity rates was similar in both groups. Median length of hospital stay was significantly increased in the 'large GIST' group (7 days vs 5 days, P = 0.004). Median follow-up was 47 months and one patient in the 'small GIST' group developed recurrence and died during follow-up 11 years after surgery. No patient died during follow-up. CONCLUSIONS: LR for large GISTs is safe and technically feasible and does not negatively influence the oncologic course. Prospective randomised trials should be performed before using this approach in routine surgical care.

Influence of body mass index on postoperative outcomes after laparoscopic liver resection.

BACKGROUND: Despite the increasing prevalence of obesity, the impact of body weight on postoperative outcomes of laparoscopic liver resection (LLR) still remains poorly evaluated. The present study aimed to explore the impact of body mass index (BMI) on perioperative outcomes in patients undergoing LLR. STUDY DESIGN: All patients undergoing LLR from January 2008 to December 2013 were retrospectively reviewed. BMI was subdivided into normal weight (<24.9 kg/m(2)), overweight (25.0-29.9 kg/m(2)), and obese (≥30.0 kg/m(2)). These three groups were compared in terms of demographic data, intraoperative factors, and postoperative outcomes. Logistic regression was used to determine odds ratios with 95% confidence intervals and evaluate BMI as an independent risk factor for morbidity. RESULTS: Among 228 selected patients, 83 (36.4%) patients were overweight and 32 (14.0%) were obese. Despite higher rates of diabetes mellitus, hypertension, and ischemic heart disease with an increase in BMI, no significant difference in operative time, blood loss, and conversion rate was observed in the three groups. There were no significant differences in postoperative mortality rate between the groups (0.9 vs. 1.2 vs. 0%). The rate of overall complications (31.0 vs. 31.3 vs. 40.6%) and major complications (14.2 vs. 9.6 vs. 18.8%) did not differ in the three groups. Major hepatectomy (HR 6.810, CI 1.437-32.267, p = 0.016) and operative time >180 min (HR 2.639, CI 1.179-5.908, p = 0.018) were independently associated with postoperative complications. CONCLUSIONS: The present study demonstrated that BMI does not negatively affect the postoperative short-term outcomes. Therefore, obesity and overweight should not be a contraindication for LLR.

Mutations in the RAS-MAPK, PI(3)K (phosphatidylinositol-3-OH kinase) signaling network correlate with poor survival in a population-based series of colon cancers.

The RAS-MAPK, PI (3)K signaling pathways form a network that play a central role in tumorigenesis. The BRAF, KRAS and PI3KCA genes code 3 partners of this network and have been found to be activated by mutation in colorectal cancer; these mutations lead to unrestricted cell growth. We evaluated the clinicopathological features and the prognosis of patients with activated-network colon cancers in a population-based study. A total of 586 colon adenocarcinomas were evaluated using sequencing for mutations of KRAS and PI3KCA, and allelic discrimination for mutation of BRAF. Clinicopathological characteristics were correlated to the risk of bearing a mutation of the network using logistic regression. Three-year survival rates were compared with the Log rank test. A multivariate survival analysis using the Cox model was performed. After adjustment for age and microsatellite instability, activation of the network by mutation of at least 1 of the 3 genes was significantly associated with female sex (p = 0.02) and proximal location (p < 0.001). Lower levels of 3-year survival were associated with activation of the network by mutation of at least 1 of the 3 genes (59.4 and 69.4%, respectively; p = 0.009). These results remained significant in a multivariate analysis adjusted for sex, age, location, stage and microsatellite instability (HR = 1.48; CI CI(95%) = [1.07-2.04]). Our study is the first report to underline the potential role of RAS-MAPK, PI (3)K network mutations on survival in colon cancers. Because of the role of this signaling network on anticancer agents, the evaluation of its mutations could have clinical implications.

Prognostic significance of MMP-1 and MMP-3 functional promoter polymorphisms in colorectal cancer.

PURPOSE: Matrix metalloproteinase (MMP) belongs to a large group of proteases capable of breaking essentially all components of the extracellular matrix. They are implicated in all steps of tumorogenesis, cancer invasion, and metastasis. Among them, metalloproteinase type 1 (MMP-1) is implicated in tumor invasion and metastasis in different types of cancers including colorectal cancer in which its expression was correlated with poor prognosis. A polymorphism in the promoter region of the MMP-1 gene leads to a variation of its level of transcription. STUDY DESIGN: MMP-1 -1607ins/delG and MMP-3 - 1612 ins/delA promoter polymorphisms were genotyped by multiplex PCR from 201 colorectal cancer patients. The median follow-up of patients was 30 months. The MMP genotypes were correlated to clinical outcome. RESULTS: Patients with the -1607insG/-1607insG MMP-1 genotype had significantly worse specific survival than the others in the whole series (P < 0.04), in stage I to III patients (P < 0.001), and in patients stage I and II (P < 0.01). In multivariate analysis, MMP-1-1607insG allele showed to be an independent poor prognostic factor after adjustment on stage, age, and the use of adjuvant chemotherapy. MMP-3 polymorphism was not associated with survival. CONCLUSIONS: In the subgroups of nondistant metatastic patients (stages I and II, and stages I-III), an inverse relation between the number of MMP-1-1607insG allele and survival was observed suggesting a gene dosage effect. Our results are consistent with the importance of MMP-1-1607ins/delG functional polymorphism in regulating transcription level and with the relationship between MMP-1 expression and cancer invasion, metastasis, and prognosis.

Thymidylate synthase gene polymorphism predicts toxicity in colorectal cancer patients receiving 5-fluorouracil-based chemotherapy.

PURPOSE: The target enzyme for 5-fluorouracil (5-FU) is thymidylate synthase (TS). The TYMS gene encoding this enzyme is polymorphic, having either double (2R) or tri-tandem (3R) repeats of a 28-bp sequence in the promoter region and a 6-bp variation in the 3'-untranslated region (3'-UTR). TS expression predicts response to 5-FU-based chemotherapy, and the expression seems to be determined by the TYMS gene promoter. The aim of this study was to investigate the utility of determining these two TYMS gene polymorphisms to predict the toxicity and efficacy of 5-FU treatment in patients with colorectal cancer. EXPERIMENTAL DESIGN: The determination of TYMS genotypes was performed in tumor and normal tissues by PCR amplification from 90 patients with colorectal cancer who were treated with adjuvant or palliative 5-FU-based chemotherapy. Associations between polymorphisms in the TYMS promoter and in the 3'-UTR gene and clinical outcome of these 90 patients treated with 5-FU based chemotherapy were evaluated individually. The linkage between TYMS promoter and TYMS 3'-UTR region polymorphisms was evaluated and a haplotype analysis was performed. RESULTS: Individuals who were homozygous for the double repeat in the TYMS promoter region had more severe side effects to 5-FU. Patients with a 2R/2R, a 2R/3R, or a 3R/3R genotype had a grade 3 or 4 toxicity rate of 43, 18, and 3% respectively (P < 0.01). The TYMS promoter and TYMS 3'-UTR polymorphisms were in linkage disequilibrium, and the haplotype 2R/ins 6-bp was significantly associated with a high risk of severe side effects to 5-FU. The TYMS promoter and TYMS 3'-UTR polymorphisms were not associated with a response to 5-FU and survival of patients who received palliative 5-FU-based chemotherapy. CONCLUSIONS: This study demonstrated that TYMS genotyping could be of help in predicting toxicity to 5-FU-based chemotherapy. TYMS genotyping might make it possible to individualize treatment for patients with colorectal cancer.

Impact of GSTT1, GSTM1, GSTP1 and NAT2 genotypes on KRAS2 and TP53 gene mutations in colorectal cancer.

Which carcinogens are of influence in the development of human colorectal cancers remains a question; one answer could be the finding that specific polymorphisms in xenobiotic metabolizing enzymes are related to particular mutations in cancer genes. KRAS2 and TP53 gene mutations as well as genotypes for GSTM1, GSTP1, GSTT1 and NAT2 were determined in an exploratory series of 165 stable colorectal cancers. Mutations in KRAS2 and TP53 were found in 34% and 57.5% of cases, respectively. The KRAS2 mutation frequency was significantly lower in patients with a GSTT1 null genotype than in those with a GSTT1 non-null genotype (18% vs. 38%, p = 0.03). The overall risk of KRAS2 mutation for patients with distal colorectal cancer and GSTT1 null genotype was 0.3 (95% CI 0.1-0.9) compared to patients with distal colorectal cancer and non-null GSTT1 genotype. The overall risk of KRAS2 mutation was similarly reduced (OR = 0.4, 95% CI 0.2-0.9) for patients with distal colorectal cancer and GSTP1 mutated genotypes compared to patients with distal colorectal cancer and wild-type genotype. Patients with GSTP1 wild-type genotype appeared to be at significantly lower risk for TP53 mutation compared to patients with mutated genotypes (p = 0.023). Our results suggest that GSTT1 and GSTP1 could play a role in the occurrence of KRAS2 and TP53 mutations in colorectal cancer and generate a hypothesis on the dietary factors that could be incriminated.

Laparoscopic gastric banding: a minimally invasive surgical treatment for morbid obesity: prospective study of 500 consecutive patients.

OBJECTIVE: To evaluate early and late morbidity of laparoscopic adjustable gastric banding for morbid obesity and to assess the efficacy of this procedure by analyzing its results. SUMMARY BACKGROUND DATA: Laparoscopic adjustable gastric banding is considered the least invasive surgical option for morbid obesity. It is effective, with an average loss of 50% of excessive weight after 2 years of follow-up. It is potentially reversible and safe; major morbidity is low and there is no mortality. METHODS: Between April 1997 and June 2001, 500 patients underwent laparoscopic surgery for morbid obesity with application of an adjustable gastric band. There were 438 women and 62 men (sex ratio = 0.14) with a mean age of 40.4 years. Preoperative mean body weight was 120.7 kg and mean body mass index (BMI) was 44.3 kg. m. RESULTS: Mean operative time was 105 minutes, 84 minutes during the last 300 operations. Mean hospital stay was 4.5 days. There were no deaths. There were 12 conversions (2.4%), 2 during the last 300 operations. Fifty-two patients (10.4%) had complications requiring an abdominal reoperation. Forty-nine underwent a reoperation for minor complications: slippage (n = 43, incisional hernias (n = 3), and reconnection of the catheter (n = 3). Three patients underwent a reoperation for major complications: gastroesophageal perforation (n = 2) and gastric necrosis (n = 1). Seven patients had pulmonary complications and 36 patients experienced minor problems related to the access port. At 1-, 2-, and 3-year follow-up, mean BMI decreased from 44.3 kg. m to 34.2, 32.8, and 31.9, respectively, and mean excess weight loss reached 42.8%, 52%, and 54.8%. CONCLUSIONS: Laparoscopic adjustable gastric banding is a beneficial operation in terms of excessive weight loss, with an acceptably low complication rate. It can noticeably improve the quality of life in obese patients. Half of the excess body weight can be effortlessly lost within 2 years.