Improving equitable access to publicly funded bariatric surgery in Queensland, Australia.

BackgroundPeople living in regional Queensland, Australia, have less access to health care than their metropolitan neighbours; a gap that is wider if they are also of Aboriginal and Torres Strait Islander ethnicity. The Bariatric Surgery Initiative (BSI) aims to provide metabolic bariatric surgery as a public service accessible to all Queenslanders for patients with morbid obesity according to need, regardless of location or ethnicity.MethodsWe investigated the BSI's progress in closing the metro-regional gap by comparing the distribution of referrals for surgery with the geographic and ethnic spread of obesity across Queensland in 2017-2019.ResultsRegional Queensland is home to 59.8% of Queensland's individuals with obesity, whereas 40.2% live in metropolitan Brisbane. In contrast, 47.8% of referrals were from regional areas, with 52.2% received from Brisbane. We found that more patients from metropolitan than regional areas underwent metabolic bariatric surgery, probably due to a paucity of referrals from regional locations. Aboriginal and Torres Strait Islander peoples were able to access the service and all patients realised significant health benefits after surgery.ConclusionsThe BSI improved access to this service, and inequities in metro-regional access may depend on patient choice and healthcare provider awareness of the BSI.Trial registrationThis initiative was a quality improvement study focused on providing access to care rather than a clinical trial; as such it was not registered as a clinical trial.

Monitoring for micronutrient deficiency after bariatric surgery-what is the risk?

BACKGROUND: Bariatric surgery may increase the risk of micronutrient deficiencies; however, confounders including preoperative deficiency, supplementation and inflammation are rarely considered. OBJECTIVE: To examine the impact of bariatric surgeries, supplementation and inflammation on micronutrient deficiency. SETTING: Two public hospitals, Australia. METHODS: Participants were recruited to an observational study monitoring biochemical micronutrient outcomes, supplementation dose, inflammation and glycaemic control, pre-operatively and at 1-3, 6 and 12 months after gastric bypass (GB; Roux-en-Y Gastric Bypass and Single Anastomosis Gastric Bypass; N = 66) or sleeve gastrectomy (SG; N = 144). Participant retention at 12 months was 81%. RESULTS: Pre-operative micronutrient deficiency was common, for vitamin D (29-30%), iron (13-22%) and selenium (39% GB cohort). Supplement intake increased after surgery; however, dose was <50% of target for most nutrients. After SG, folate was vulnerable to deficiency at 6 months (OR 13 [95% CI 2, 84]; p = 0.007), with folic acid supplementation being independently associated with reduced risk. Within 1-3 months of GB, three nutrients had higher deficiency rates compared to pre-operative levels; vitamin B1 (21% vs. 6%, p < 0.01), vitamin A (21% vs. 3%, p < 0.01) and selenium (59% vs. 39%, p < 0.05). Vitamin B1 deficiency was independently associated with surgery and inflammation, selenium deficiency with improved glycaemic control after surgery and inflammation, whilst vitamin A deficiency was associated with inflammation only. CONCLUSION: In the setting of prophylactic post-surgical micronutrient prescription, few nutrients are at risk of de novo deficiency. Although micronutrient supplementation and monitoring remains important, rationalising high-frequency biochemical testing protocols in the first year after surgery may be warranted.

Health outcomes of patients with type 2 diabetes following bariatric surgery: Results from a publicly funded initiative.

OBJECTIVE: Bariatric surgery is an effective treatment for type 2 diabetes and morbid obesity. This paper analyses the clinical and patient-reported outcomes of patients treated through the Bariatric Surgery Initiative, a health system collaboration providing bariatric surgery as a state-wide public service in Queensland, Australia. RESEARCH DESIGN AND METHODS: A longitudinal prospective cohort study was undertaken. Eligible patients had type 2 diabetes and morbid obesity (BMI ≥ 35 kg/m2). Following referral by specialist outpatient clinics, 212 patients underwent Roux-en-Y gastric bypass or sleeve gastrectomy. Outcomes were tracked for a follow-up of 12-months and included body weight, BMI, HbA1c, comorbidities, health-related quality of life, eating behaviour, and patient satisfaction. RESULTS: Following surgery, patients' average body weight decreased by 23.6%. Average HbA1c improved by 24.4% and 48.8% of patients were able to discontinue diabetes-related treatment. The incidence of hypertension, non-alcoholic steatohepatitis, and renal impairment decreased by 37.1%, 66.4%, and 62.3%, respectively. Patients' emotional eating scores, uncontrolled eating and cognitive restraint improved by 32.5%, 20.7%, and 6.9%, respectively. Quality of life increased by 18.8% and patients' overall satisfaction with the treatment remained above 97.5% throughout the recovery period. CONCLUSIONS: This study confirmed previous work demonstrating the efficacy of publicly funded bariatric surgery in treating obesity, type 2 diabetes and related comorbidities, and improving patients' quality of life and eating behaviour. Despite the short follow-up period, the results bode well for future weight maintenance in this cohort.

Plasma and Interstitial Fluid Pharmacokinetics of Prophylactic Cefazolin in Elective Bariatric Surgery Patients.

Guidelines for surgical prophylactic dosing of cefazolin in bariatric surgery vary in terms of recommended dose. This study aimed to describe the plasma and interstitial fluid (ISF) cefazolin pharmacokinetics in patients undergoing bariatric surgery and to determine an optimum dosing regimen. Abdominal subcutaneous ISF concentrations (measured using microdialysis) and plasma samples were collected at regular time points after administration of cefazolin 2 g intravenously. Total and unbound cefazolin concentrations were assayed and then modeled using Pmetrics. Monte Carlo dosing simulations (n = 5,000) were used to define cefazolin dosing regimens able to achieve a fractional target attainment (FTA) of >95% in the ISF suitable for the MIC for Staphylococcus aureus in isolates of ≤2 mg · L-1 and for a surgical duration of 4 h. Fourteen patients were included, with a mean (standard deviation [SD]) bodyweight of 148 (35) kg and body mass index (BMI) of 48 kg · m-2. Cefazolin protein binding ranged from 14 to 36% with variable penetration into ISF of 58% ± 56%. Cefazolin was best described as a four-compartment model including nonlinear protein binding. The mean central volume of distribution in the final model was 18.2 (SD 3.31) L, and the mean clearance was 32.4 (SD 20.2) L · h-1. A standard 2-g dose achieved an FTA of >95% for all patients with BMIs ranging from 36 to 69 kg · m-2. A 2-g prophylactic cefazolin dose achieves appropriate unbound plasma and ISF concentrations in obese and morbidly obese bariatric surgery patients.

Feasibility of resection and plication "RAP" technique for management of medically refractory GERD in patients with altered gastric anatomy.

Background and study aims Gastroesophageal reflux disease (GERD) is common, especially in patients after gastric surgery. Medical management of GERD is ineffective in up to 30 % patients and revisional gastric surgery for management of GERD is associated with higher morbidity. We aimed to assess the safety, feasibility, and efficacy of a novel endoscopic resection and plication (RAP) anti-reflux procedure for management of medically refractory GERD in patients with altered gastric anatomy. Patients and methods The RAP procedure involves endoscopic mucosal resection and full-thickness plication over the right posterior-medial axis extending 15 mm above and 20 to 30 mm below the squamocolumnar junction. Adverse events, technical feasibility, GERD health-related quality-of-life (GERD-HRQL) scores, and medication use were prospectively recorded. Results Twenty consecutive patients with previous gastric surgery underwent RAP between September 2018 and August 2020 with a median follow-up of 5.7 months. The median procedure duration was 66 minutes (IQR 53.8-89.5). RAP was technically successful in 19 patients. One patient developed gastric hemorrhage from suture dehiscence, which was managed endoscopically, and four patients developed esophageal stricture requiring endoscopic dilation. Following the RAP procedure, significant improvement in GERD-HRQL score was observed (mean 26.9, 95 %CI 23.36-30.55, P  < 0.01). Fourteen of 19 patients reported > 50 % improvement in GERD-HRQL scores. Sixteen of 18 patients reported reduction in requirement for or cessation of antacid therapy. Conclusions Patients with refractory GERD after gastric surgery have limited therapeutic options. We have demonstrated that the RAP procedure is feasible, safe, and clinically effective at short-term follow-up. It provides a potential alternative to revisional surgery in patients with altered gastric anatomy.

Revisional bariatric surgery to single-anastomosis gastric bypass: a large multi-institutional series.

BACKGROUND: Reoperation is often required after bariatric procedures. Single-anastomosis gastric bypass (SAGB) is increasingly utilized as a primary bariatric procedure. Few series document SAGB as a revisional bariatric procedure. OBJECTIVES: To describe our short-term experience with revisional SAGB, focusing on weight loss and reflux symptom outcomes. SETTING: Three hospitals in Australia with both private and public (government funded) patients. METHODS: We reviewed all revisional SAGB cases from 2012 to 2019 at. Complications were considered significant if they were Clavien-Dindo grade 3a or higher. A phone survey was conducted to assess weight loss outcomes, patient satisfaction, reflux symptoms, and other complications. RESULTS: We identified 254 patients who had a revisional bariatric procedure to SAGB (21 previous sleeve gastrectomies and 233 previous adjustable bands), with a mean follow-up of 22 ± 15.6 months (range, 1-55 mo). The mean percentage of excess weight loss was 77% (183 patients, 72%), and the number of patients with follow-ups at 1 and 4 years was 184 (73%) and 35 patients (14%). Within 30 days, there were 29 patients (11%) who required reinterventions (21 endoscopies, 1 interventional radiology procedure, and 7 reoperations) with no deaths. Beyond 30 days, 27 patients (11%) required rerevision to Roux-en-Y gastric bypass for reflux symptoms and 10 (4%) required a laparotomy or laparoscopy for another reason (e.g., bowel obstruction). At a median follow-up of 36.6 months, 87 patients (34%) completed a phone survey, 45 (52%) of whom were taking proton pump inhibitors and 66 patients (76%) of whom were satisfied with their experience. CONCLUSION: In our series, revision to SAGB was safe, with low short-term morbidity and favorable weight loss outcomes. However, beyond 1 year, a large proportion of patients experienced severe reflux symptoms and required rerevision.

Iron, Vitamin B12, Folate and Copper Deficiency After Bariatric Surgery and the Impact on Anaemia: a Systematic Review.

Bariatric surgery may increase the risk of iron, vitamin B12, folate and copper deficiencies, which can cause anaemia. This review aims to critique the evidence on the prevalence of these nutritional deficiencies and the impact on anaemia in the first 12 months after surgery. PRISMA and MOOSE frameworks, the NHMRC evidence hierarchy and The Academy of Nutrition and Dietetics bias tool were used to systematically critique current literature. Seventeen studies reported on deficiency prevalence with the majority being of low quality. Important confounders to serum micronutrient levels were not adequately considered. Results on the prevalence of nutritional anaemias were also lacking. Further investigation into the prevalence of iron, vitamin B12, folate and copper deficiency and its impact on anaemia in bariatric surgery is needed.

Medium-term outcomes of converting laparoscopic adjustable gastric band to Roux-en-Y gastric bypass in patients with body mass index <35 kg/m2: a uniquely Australian perspective.

BACKGROUND: The rates of primary laparoscopic adjustable gastric banding (LAGB) have declined in the last 5 years due to band removal secondary to complications and the subsequent weight regain that requires revisional procedures. OBJECTIVES: This study aimed to present medium-term weight loss results and the safety profile of converting LAGB to Roux-en-Y gastric bypass in patients with body mass index (BMI) <35.0 kg/m2 who presented with LAGB intolerance or complications. Many health services do not permit such procedures on low BMI patients. SETTINGS: Single-surgeon series, including public and private practice, Brisbane, Australia. METHOD: A prospectively maintained database was reviewed and retrospectively analyzed for LAGB patients with a BMI <35.0 kg/m2 who underwent conversion to Roux-en-Y gastric bypass by a single surgeon. Indications for conversion, weight loss data, and early (30 d postoperative) and late complications were recorded with follow-up out to 5 years. RESULTS: One hundred thirty-two adult patients with a BMI <35.0 kg/m2 underwent conversion from 2009 to 2016. The main indications for conversion were reflux and band complications. Median BMI at bypass was 32.8 kg/m2 (23.1-35.0). Median percentage excess weight loss was 77%, 90%, 73%, 47%, 49%, and 44% at 1, 2, 3, 4, and 5 years, respectively among patients who were eligible and present at follow-up. Median BMI was <30.0 kg/m2 (29.1-40.9) at 5 years with only 1 subject exceeding >35.0 kg/m2. Mortality was 0%. Early morbidity occurred in 31.8% of patients. The most common late complication was gastrojejunostomy stricture requiring endoscopic dilation. CONCLUSIONS: In combination with our 2014 study showing morbidity data in the short-term period being comparable to patients with BMI >35.0 kg/m2, our study demonstrates that converting LABG to Roux-en-Y gastric bypass in low BMI patients is a feasible and safe option that avoids weight regain and maintains adequate weight loss at 5 years, with acceptable morbidity and no mortality.

Does Bariatric Surgery Cause Vitamin A, B1, C or E Deficiency? A Systematic Review.

BACKGROUND: The restrictive and/or malabsorptive nature of bariatric surgery may increase the risk for micronutrient deficiencies. This systematic review aimed to identify and critique the evidence for vitamin A, B1, C or E deficiencies associated with bariatric surgery. METHODS: This review utilised PRISMA and MOOSE frameworks with NHMRC evidence hierarchy and the American Dietetic Association bias tool to assess the quality of articles. RESULTS: Twenty-one articles were included and once critiqued all studies were of level IV grade and neutral or negative in quality. The relevance of measuring micronutrient supplementation and inflammatory markers for validity of serum vitamins is absent within the literature. CONCLUSIONS: Future research is needed to investigate the risk of deficiency for these procedures with focus on confounders to serum micronutrients.

Outcomes of laparoscopic sleeve gastrectomy in Crohn's disease patients: an initial Australian experience.

BACKGROUND: Crohn's disease (CD) in association with obesity is becoming an increasing issue in Australia and worldwide. This report looks at outcomes for patients with CD undergoing laparoscopic sleeve gastrectomy. METHODS: This is a retrospective analysis of our database of patients undergoing laparoscopic sleeve gastrectomy from 2007 to 2016. Patients with concurrent CD were included. RESULTS: Eight patients with CD underwent laparoscopic sleeve gastrectomy with a mean preoperative body mass index of 43.8. There were no identified intraoperative or post-operative complications. The mean excess weight loss was 55.7% and 56.5% at 6 months and 1 year, respectively. CONCLUSION: Laparoscopic sleeve gastrectomy can be achieved in CD patients. No complications and effective weight loss was observed in the eight reported patients.

Portomesenteric vein thrombosis in sleeve gastrectomy: a 10-year review.

BACKGROUND: Worldwide, the laparoscopic sleeve gastrectomy (LSG) is becoming the dominant bariatric procedure due to its reliable weight loss and low complication rate. Portomesenteric vein thrombosis (PVT) is an uncommon complication of LSG with an incidence of .3% to 1% and can lead to serious consequences, such as bowel ischemia and death. OBJECTIVES: This paper will present the presentation, risk factors, treatment, and long-term outcomes of patients who had PVT post-LSG. SETTING: Five bariatric centers in a private setting in Australia. METHODS: Retrospective data were collected from 5 bariatric centers across Australia from 2007 to 2016. RESULTS: Across 5 centers, 5951 patients underwent LSG; 18 had recognized PVT (.3%). The mean body mass index was 41.8. Of patients, 39% had a history or family history of deep vein thrombosis. The average time to diagnosis was 13 days (range, 5-25). Treatment was nonoperative with anticoagulation in 94%. One patient required operative management with bowel resection. All patients were discharged on therapeutic anticoagulation. Mean total weight loss was 27.7% (14.8%-66.3%). Mean follow-up was 10 months. There were no mortalities. Given the low number of patients, no statistically significant data could be derived. CONCLUSION: PVT is difficult to diagnose, with significant consequences. The presenting symptoms are nonspecific, and a high index of suspicion needs to be maintained. Cross-sectional imaging with computed tomography of the abdomen is recommended. Patients with PVT post-LSG without previous risk factors can be anticoagulated for 3 to 6 months with an international normalized ratio of 2 to 3.

Revision gastric bypass after laparoscopic adjustable gastric band: a 10-year experience at a public teaching hospital.

BACKGROUND: In Australia, there is limited access to public revisional bariatric procedures. However, the need for such procedures is rising. We investigated the safety and efficacy of band-to-bypass procedures in our experience at a public teaching hospital over a period of 10 years. METHODS: Using a prospectively maintained bariatric surgical database, we analysed 91 consecutive planned band-to-bypass procedures from 2007 to November 2016. All patients had prior laparoscopic adjustable gastric bands removed and formation of Roux-en-Y gastric bypass, in one or two stages. Primary outcomes were 30-day complication rate and excess weight loss from 12 months. The impact of fellows as primary operators on these outcomes was assessed. RESULTS: Eighty-two patients met the inclusion criteria. Seventy-one (84.5%) were females. Mean age was 48.8 years (SD: 8.85). Immediate post-operative complications included six (7.3%) patients with gastrojejunostomy leak, three of whom required conversion to laparotomy, with one mortality (1.22%). Fifty-two patients had follow-up of 1 year or more (median: 2.36, range: 1-9.24). Mean excess weight loss at the end of follow-up was 52.79% (SD: 46.46). Twenty-eight (34.14%) cases were performed primarily by a fellow under the guidance of an experienced bariatric surgeon, with equivalent results. CONCLUSION: Revisional band-to-bypass in the public setting is an effective but complex procedure associated with morbidity. Some risk may be ameliorated by development of selection criteria to exclude certain high-risk groups. We hope discussion amongst other bariatric groups will further refine this approach.

A 12-Month Review of Revisional Single Anastomosis Gastric Bypass for Complicated Laparoscopic Adjustable Gastric Banding for Body Mass Index over 35.

BACKGROUND: In many countries, laparoscopic adjustable gastric banding (LAGB) was previously the most commonly performed bariatric procedure due to its operative safety and early efficacy. This procedure is now superseded because of doubtful long-term results and late complications. Many people eventually required revisional bariatric surgery such as conversion to single anastomosis gastric bypass (SAGB). This study aims to assess the safety and durability of single-stage conversion from LAGB to SAGB in patients who are intolerant to LAGB and who also fail to lose weight, or re-gain weight. METHODS: Seventy-four patients with BMI > 35 kg m-2 were selected from a prospective bariatric database between July 2012 and December 2015 for revisional laparoscopic SAGB surgery and were followed up at 6 weeks, 3, 6 and 12 months after their operation. RESULTS: The mean BMI at 6 weeks, then 3, 6 and 12 months were 41.6 ± 7.66, 38.8 ± 7.54, 35.4 ± 7.10 and 33.2 ± 7.34 kg m-2, respectively. The mean percentage EWL at 6 weeks then 3, 6 and 12 months were 21.0 ± 9.12, 37.8 ± 12.5, 55.1 ± 15.8 and 67.0 ± 19.6%, respectively. Postoperative follow-up at these times were 97, 85, 69 and 46%, respectively. Early (< 30 day) morbidity was 20.3% with major complications of CD grade 3a or more of 13.5%. CONCLUSIONS: This study demonstrates that single-stage revisional SAGB after a failed LAGB achieved good short-term weight loss and low 30-day morbidity.

Laparoscopic adjustable gastric band revisional surgery: a single surgeon series.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is a safe and proven surgical option for morbid obesity; however, the need for revisional surgery is being increasingly reported. This study reports outcomes and incidence for a large cohort of patients requiring revisional LAGB surgery for various indications. METHODS: A retrospective review of prospectively collected data for 1524 primary LAGB placed between 2003 and 2013 by a single surgeon at a single institution was performed, analysing data for all patients in this cohort requiring revisional LAGB surgery. RESULTS: A total of 434 revisions were performed on 349 patients. A total of 278 patients had a single revision, with 71 patients having two or more revisions. Revisions amounting to 213 were band repositions, 68 were band removal only and 153 were band removal with conversion to another bariatric procedure, mostly Roux-en-Y gastric bypass (n = 143). A total of 47 (35.1%) 'band-to-band' revision patients were lost to follow-up. Patients undergoing 'band-to-band' revision for a slipped band, patient intolerance and mechanical band failure had mean excess weight loss (EWL) at 4 years of 49.9% (n = 35), 38.6% (n = 10) and 67.4% (n = 6), respectively. Port or tubing revisions were not included. Mean follow-up for 'band-to-band' revision patients was 33.4 months (standard deviation 26.4 months). 22.9% of patients required one or more band revision procedures by 2013, increased from 13% in 2008. CONCLUSION: Continued EWL is achieved with repositioning or replacement of a LAGB. However, a significant and increasing rate of re-operation over time exists.

A prospective study of the impact of fluorodeoxyglucose positron emission tomography with concurrent non-contrast CT scanning on the management of operable pancreatic and peri-ampullary cancers.

BACKGROUND: The role of fluorodeoxyglucose (FDG) positron emission tomography (PET/CT) scanning in operable pancreas cancer is unclear. We, therefore, wanted to investigate the impact of PET/CT on management, by incorporating it into routine work-up. METHODS: This was a single-institution prospective study. Patients with suspected and potentially operable pancreas, distal bile duct or ampullary carcinomas underwent PET/CT in addition to routine work-up. The frequency that PET/CT changed the treatment plan or prompted other investigations was determined. The distribution of standard uptake values (SUV) among primary tumours, and adjacent to biliary stents was characterised. RESULTS: Fifty-six patients were recruited. The surgical plan was abandoned in 9 (16%; 95% CI: 6-26) patients as a result of PET/CT identified metastases. In four patients, metastases were missed and seven were inoperable at surgery, not predicted by PET/CT. Unexpected FDG uptake resulted in seven additional investigations, of which two were useful. Among primary pancreatic cancers, a median SUV was 4.9 (range 2-12.1). SUV was highest around the biliary stent in 17 out of 28 cases. PET/CT detected metastases in five patients whose primary pancreatic tumours demonstrated mild to moderate avidity (SUV < 5). CONCLUSIONS: PET/CT in potentially operable pancreas cancer has limitations. However, as a result of its ability to detect metastases, PET/CT scanning is a useful tool in the selection of such patients for surgery.

Roux-en-Y gastric bypass after successful weight loss with a laparoscopic adjustable gastric band: rationales and early outcomes in patients of body mass index<35 kg/m(2.).

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) has a number of well-established acute and chronic issues that can require revisional surgical procedures. There is no existing data to evaluate conversion of band patients with body mass index (BMI)<35 kg/m(2) from LAGB to a Roux-en-Y gastric bypass (RYGB). This study aims to report on the indications for and the safety profile of conversion of the LAGB to RYGB in patients with BMI<35 kg/m(2). METHODS: A review of data from 200 consecutive conversions of LAGB to RYGB was conducted. Fifty-two patients whose BMI was<35 kg/m(2) were included in this analysis. Indications for conversion, technical details, early morbidity, length of hospital stay, and weight loss data were assessed. RESULTS: Laparoscopic conversion to RYGB was performed in 100% of patients. The median BMI pre-RYGB was 32.8 kg/m(2). The most common indication for surgery was weight regain after removal of LAGB (28.8%). There was no mortality. Early morbidity was seen in 25% of patients; the most common complication was stricture of the gastrojejunal anastomosis (9 patients). CONCLUSION: Morbidity resulting from conversion of LAGB to RYGB in patients with BMI <35 kg/m(2) is similar to that seen in the BMI>35 kg/m(2) population. The procedure is technically challenging and morbidity rates are higher than those reported for surgically 'naïve' patients. It is recommended that this procedure be undertaken by appropriately trained surgeons in high-volume bariatric centers to optimize safety and outcomes.

Laparoscopic revision of gastric band surgery.

AIM: To identify the outcome of laparoscopic revision of gastric band surgery with respect to percentage of excess weight lost (%EWL). METHODS: Analysis of a prospective database was then performed and %EWL was plotted with respect to time from initial procedure and also time from revision procedure. RESULTS: All revision operations were performed laparoscopically. There were no patient deaths, but two serious complications. Percentage excess weight loss after replacement of the band because of prosthetic failure or dysphagia was 57% at an average follow-up of 19 months. For repositioning of the band due to slippage, the %EWL was 72% at an average of 15 months follow-up for those who had the existing band repositioned, and 42% at an average of 23 months follow-up for those who had a new band repositioned. CONCLUSION: Revision laparoscopic gastric band surgery is a safe option for patients, and results in good %EWL at an average follow-up period of 19 months.

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.

Laparoscopic gastric banding in morbidly obese adolescents.

BACKGROUND: 4% of adolescents in the U.S.A. are obese, 80% of whom will become obese adults. Obesity in adolescence is associated with increased mortality and morbidity in adulthood. Is laparoscopic adjustable silicone gastric banding a safe and effective method of weight loss in morbidly obese adolescents? METHODS: Since 1996, data has been prospectively collected on all patients undergoing laparoscopic adjustable gastric banding (LAGB) by a single surgeon. Patients are reviewed at 6 and 12 weeks following surgery, then at 3 monthly intervals. Weight loss is measured in absolute terms, reduction in body mass index (BMI) and as percentage of excess weight loss. RESULTS: 17 patients with a median age of 17 (12 to 19) years underwent LAGB. Median follow-up was 25 (12 to 46) months. 2 complications occurred, 1 slipped band and 1 leaking port. BMI fell from a preoperative median of 44.7 to 30.2 kg/m2 at 24 months following surgery, corresponding to a median loss of 35.6 kg or 59.3% of excess weight. 13 of 17 patients (76.5%) lost at least 50% of their excess weight, and 9 of 11 patients (81.8%) had a BMI < 35 kg/m2 at 24 months following surgery. CONCLUSION: LAGB is a safe and effective method of weight loss in morbidly obese adolescents, at least in the medium term. Its role in preventing obesity and obesity-related disease in adulthood remains to be determined as part of our long-term study.