Clinical Outcomes of Laparoscopic Greater Curvature Plication and Laparoscopic Sleeve Gastrectomy: a Case-Matched Control Study.

BACKGROUND: Laparoscopic greater curvature plication (LGCP) is a new bariatric procedure that is similar to laparoscopic sleeve gastrectomy (LSG) in that it uses a restrictive mechanism. Comparative studies between LGCP and LSG were still limited. The aim of this study was to compare the clinical outcomes of the two procedures based on the same clinical conditions. METHODS: From January 2012 to December 2015, 260 patients with morbid obesity underwent LGCP and LSG in a single center. Data on patient demography, operation time, complications, hospital stay, body mass index loss, percentage of excess weight loss (%EWL), and improvement in comorbidities were collected. A propensity-matched analysis, incorporating pre-operative variables, was used to compare the short-term outcomes between LGCP and LSG. RESULTS: Propensity matching produced 48 patients in each group. Patients who underwent LGCP were predominately female (75.5%, 41.1% of the LSG patients were female, p = 0.028). Baseline BMI and excess weight were significantly lower in the LGCP group (p < 0.001). The LSG group showed a greater decrease in excess body weight than the LGCP group (LSG, 47.36 ± 12.95% in 3 months, 57.97 ± 19.28% in 6 months, 66.28 ± 25.42% in 12 months; LGCP, 39.67 ± 12.58% in 3 months, 47.40 ± 19.30% in 6 months, 48.02 ± 20.17% in 12 months, p = 0.008, 0.032, 0.010). Perioperative complications and resolution of obesity-related comorbidities were not significantly different between the two groups. CONCLUSION: LGCP and LSG are both feasible and safe procedures for surgical weight reduction. In short-term follow-ups, LSG demonstrates a better excess body weight reduction while having perioperative complications similar to LGCP.

Revisional Malabsorptive Bariatric Surgery: 29-Year Follow-up in a Brazilian Public Hospital.

BACKGROUND: This study aimed to evaluate the outcomes of 67 patients who underwent revisional bariatric surgeries over a 29-year period in a Brazilian public hospital. METHODS: The records of all patients who underwent revisional bariatric surgery from January 1987 to December of 2016 at our hospital were analyzed for weight loss and complications. Descriptive statistics and paired t tests were computed. RESULTS: Sixty-seven patients were included in the study. The primary surgeries previously performed on these patients were biliopancreatic diversion with duodenal switch (BPD-DS) (37 cases, 55.2%), jejunoileal bypass (JIB) (24 cases, 35.8%), sleeve gastrectomy (4 cases, 5.9%), Roux-en-Y gastric bypass (RYGB) (1 case, 1.5%), and laparoscopic adjustable gastric band (1 case, 1.5%). The indications for revisional surgery were as follows: malnutrition in 29 cases (43.3%), failure to lose weight in 27 cases (40.3%), weight regain in 5 cases (7.5%), and untreatable diarrhea in 6 cases (9.2%). Most revisional surgeries were performed using JIB or BPD-DS. Operative mortality was higher after the revisional procedures compared with that following the primary bariatric surgeries. CONCLUSIONS: Most patients requiring a revisional surgery had undergone a primary BPD-DS or JIB. Severe and untreatable malnutrition and diarrhea were the main indications for the revisional procedures. RYGB produced significant and sustainable weight loss and exhibited a low risk of malnutrition or requiring revisional surgery.

Safety and Effectiveness of Single-Anastomosis Duodenal Switch Procedure: 2-Year Result from a Single US Institution.

BACKGROUND: Single-anastomosis duodenal switch (DS) was introduced by Sanchez-Pernaute et al. as a modification of the biliopancreatic diversion with duodenal switch. We have published preliminary results of the loop DS as the first report of the procedure in the USA. This study aims to evaluate the loop DS procedures again, in terms of weight loss, comorbidity resolution, complication rate, and address the nutritional concerns. METHODS: A retrospective chart review was performed on initial 128 patients who underwent laparoscopic or robot-assisted laparoscopic single-stage loop DS between December 17, 2013 and September 23, 2016. Sixteen additional patients were prospectively enrolled from September 24, 2016 to May 4, 2017. RESULTS: A total of 102 female and 38 male patients were included in this study with a mean age of 41.2 ± 9.6 years. The mean body mass index (BMI) at the time of procedure was 57.3 ± 9.2 kg/m2. Percentage of total weight loss was 23.1, 37.1, 42.9, and 44.7% at 6, 12, 18, and 24 months, respectively. Percentage of excess BMI loss was 41.9, 68.1, 76.6, and 80.8% at 6, 12, 18, and 24 months, respectively. Mean levels of HbA1c, triglyceride, and LDL-cholesterol decreased significantly after the loop DS. Regarding the fat-soluble vitamins, majority of patients had vitamin A and E levels in the normal range. However, 42 to 56% of the patients had low levels of vitamin D at 6, 12, and 24 months following the procedure. Mean length of hospital stay was 4.1 ± 2.7 days. Thirty-day readmission rate was 7.6% (n = 11), and 30-day reoperation rate was 6.9% (n = 10). CONCLUSIONS: Loop DS seems to be effective in weight loss and is a feasible operation in the super-obese population. However, close monitoring of liver enzymes is warranted in addition to nutritional follow-up.

Laparoscopic hand-sewn revisional gastrojejunal plication for weight loss failure after Roux-en-Y gastric bypass.

BACKGROUND: Revisional surgery has become a widely accepted alternative for weight loss failure/regain after bariatric surgery. However, it is associated to higher morbi-mortality and lesser weight loss than primary bariatric procedure. Our aims are to present a novel technique for weight loss treatment after failed laparoscopic Roux-en-Y gastric bypass (LRYGB) and to report its short-term results. METHODS: This is a retrospective analysis of patients submitted to a revisional hand-sewn double-layer gastrojejunal plication (GJP) for treatment of weight loss failure/regain after LRYGB. Analysis of demographics, body mass index (BMI), and percentage of excess weight loss (%EWL) at the 6th month complications, and financial costs involved was included. RESULTS: Four patients were submitted to revisional GJP. Three patients were female and the mean age at revision was 30 ± 9 years (21-44). The median time interval between LRYGB and GJP was 51 months (24-120). The median BMI at the moment of GJP and the 3rd and 6th month was 35.6 kg/m2 (32.0-37.8), 32.2 kg/m2 (29.7-34.1), and 30.7 kg/m2 (28.1-32.1), respectively. The median %EWL at the 3rd and 6th month was 35.4% (13.6-38.9) and 46.2 % (45.1-55.5), respectively, reaching a cumulative (combined surgeries) %EWL of 62.9% (16.5-67.9) and 71.7% (65.1-77.6), respectively. There were no complications or mortality. Financial costs were significantly lower compared to revisional gastrojejunal stapled reduction (US $1400 cheaper). CONCLUSION: Revisional GJP is a feasible, safe, and cost-effective novel procedure for treatment of weight loss failure/regain after LRYGB. Mid- and long-term results are necessary in order to establish its real effectiveness.

La obesidad en la historia de la cirugía / Obesity in the history of surgery

La obesidad ha alcanzado dimensiones epidémicas mundiales y la cirugía bariátrica, prácticamente desconocida, ha logrado un desarrollo difícil de imaginar hace pocas décadas. No obstante, no puede decirse que la obesidad no existiese en la antigüedad o sea una patología de conocimiento reciente. Ya en la Edad de Piedra hay testimonios de su existencia y los grandes maestros de la medicina Hipócrates (460-355 a.C.) y Galeno (131-201 d.C.) conocían perfectamente la enfermedad y sus consecuencias e incluso los tratamientos médicos actuales remedan los que ellos prescribían. La cirugía comienza esencialmente a mediados del siglo xx, aunque al final del xix ya se dan los primeros pasos experimentales en la comprensión de la fisiopatología de la hipoabsorción intestinal como base del adelgazamiento, o el auge de la resección gástrica por úlcera péptica permite observar que la restricción de la capacidad del estómago promueve la pérdida de peso. Hipoabsorción y restricción gástrica, solas o combinadas, han llegado a nuestros días como principios quirúrgicos inalterables. Sin embargo, como todo tratamiento no etiológico, la cirugía bariátrica es una solución imperfecta para una enfermedad incurable, la obesidad mórbida. Prevención y conocimientos genéticos o moleculares, entre otros, permitirán un tratamiento integral, médico o quirúrgico, adaptado a cada situación clínica del paciente (AU)

Obesity is a problem that is reaching epidemic proportions throughout the world and bariatric surgery is now a rapidly growing technique. However existence of obesity in humans has been recognized for thousands of years, as statues dating from the Stone Age period appear to provide the earliest depictions. Hippocrates (466-355 b.C.) and Galen (131-201 a.C.) had a clear understanding of the condition, its consequences and medical treatment. On the other hand bariatric surgery was a xx century treatment, but at the end of the xix century it was known that the massive loss of small bowel or gastric resection after ulcer surgery resulted in persistent weight loss. Malabsorption and gastric restriction in isolation, or more commonly in combination, remain the main options to surgical control of weight. Unfortunately surgery as a non etiological treatment is an imperfect model to treat an incurable disease: morbid obesity. Prevention and better knowledge of disease would allow a tailored medical or surgical approach (AU)

Bariatric surgery worldwide 2003.

BACKGROUND: There is a world epidemic of overweight, obesity, and morbid obesity, encompassing 1.7 billion people. Bariatric surgery today is the only effective therapy for morbid obesity. METHODS: E-mail requests for information were sent to the presidents of the national societies of the 31 International Federation for the Surgery of Obesity (IFSO) nations, or national groupings, plus Sweden. Responses were tabulated; calculation of relative prevalence of specific procedures was done by weighted averages. RESULTS: Responders were 26 of 32 (81%) for the general questions and 24 of 32 (75%) for the question on specific operative percentages. In the year 2002-2003, 146,301 bariatric surgery operations were performed by 2,839 bariatric surgeons; 103,000 of these operations were performed in USA/Canada by 850 surgeons. The earliest start date for bariatric surgery was 1953 in the USA; IFSO was founded in 1995. In the year 2002-2003, 37.15% of operations were open; 62.85% laparoscopic. The 6 most popular procedures by weighted averages were: laparoscopic gastric bypass, 25.67%; laparoscopic adjustable gastric banding, 24.14%; open gastric bypass, 23.07%; laparoscopic long-limb gastric bypass, 8.9%; open long-limb gastric bypass, 7.45%; and open vertical banded gastroplasty, 4.25%. Pooling open and laparoscopic procedures, relative percentages were: gastric bypass, 65.11%; gastric banding, 24.41%; vertical banded gastroplasty, 5.43%; and biliopancreatic diversion/duodenal switch, 4.85%. Categorizing into restrictive/malabsorptive, purely restrictive, and primarily malabsorptive, the relative distribution of procedures was 65.11%, 29.84%, and 4.85%, respectively. The number of countries performing gastric banding was 23 (95%), gastric bypass 21 (88%), vertical banded gastroplasty 19 (79%), and biliopancreatic diversion/duodenal switch 16 (67%). Purely restrictive procedures were performed in 24 (100%) of the countries, restrictive/malabsorptive in 21 (88%), and primarily malabsorptive in 18 (75%). CONCLUSIONS: Bariatric surgery is expanding exponentially to meet the global epidemic of morbid obesity. Operative procedures in bariatric surgery are in flux and specific geographic trends and shifts are evident. Yet, of the patients qualifying for surgery, only about 1% are receiving this therapy--the only effective treatment currently available.

Time trends in obesity surgery 1987 through 1996 in Sweden--a population-based study.

BACKGROUND: The Swedish health-care system is well suited for surveys of incidence of surgical procedures including those for morbid obesity, since almost all hospital care is provided by public hospitals funded by a public health-care insurance system. The National Board of Health and Welfare keeps a nation-wide registry of all in-patient hospital care. In order to describe the practice of obesity surgery, we extracted data for all patients who had undergone obesity surgery between 1987 and 1996. MATERIAL: 6,339 patients had at least one obesity surgery procedure between Jan. 1987 and Dec. 1996. A total of 7,176 procedures were identified. 77.2% were women, and the mean age was 39 years. Hospital stay averaged 8 days. RESULTS: There was a 3-fold increase in the annual incidence from 312 procedures/year in 1987 to 952 in 1996. 14% of the patients operated in1996 had previously undergone obesity surgery during the study period. The hospital mortality was 0.4%. Simple gastric restrictive procedures dominated (76%), and gastric bypass and jejuno-ileal bypass were performed in 7.5% and 5%, respectively. There was a trend that gastric bypass was performed more frequently towards the end of the study period. An increased number of procedures were performed in smaller hospitals during 1994-96, and there were obvious geographical variations. CONCLUSION: There has been 3-fold increase in obesity surgery in Sweden between 1987 and 1996, accounted for by increased performance of simple gastric restrictive procedures. The operative mortality is low, but the incidence of a second obesity surgery procedure is high.

Obesity surgery in Russia.

BACKGROUND: In Russia, 40% of the population are overweight, and 26% are obese. As was mentioned at the IFSO Symposium in Cancun, very little is known about obesity surgery in Russia. METHODS: The authors undertook a literature search and interviewed surgeons who are known to perform bariatric procedures. RESULTS: Jejunoileal bypass (JIB) was used in the 1970s but has been abandoned by most surgeons. Since 1977, 334 JIBs, of a total of 360 bariatric operations, have been performed at I Saint Petersburg Medical University. The remaining 26 operations included 14 gastric bandings, 6 horizontal and 4 vertical gastroplasties, and 2 gastric bypasses. Since 1984, 545 gastric banding procedures have been done at the Moscow Medical Academy, where the current approach is the lap-band type of gastric banding. The laparoscopic technique of adjustable gastric banding is beginning to be used. Vertical banded gastroplasty (VBG) was begun in the early 1990s. At the Russian Research Center of Surgery in Moscow, 48 Mason VBGs have been done. The other group in Moscow reported 28 VBGs without the creation of a window and including covering the stoma by polypropylene mesh. There are only a few known cases of gastric bypass procedures. No data on biliopancreatic diversion were found. CONCLUSIONS: Obesity surgery is not being performed enough to satisfy the requirements of the Russian population. Simple operations are more common than complex ones. The use of the laparoscopic approach has begun and probably will increase.

Long-term consequences after jejunoileal bypass for morbid obesity.

This study assesses the long-term results of jejunoileal bypass (JIB) in 43 prospectively followed patients whose surgical bypass remained intact. Follow-up was 12.6+/-0.25 years from JIB. Weight loss and improved lipid levels, glucose tolerance, cardiac function, and pulmonary function were maintained. Adverse effects such as hypokalemia, cholelithiasis, and B12 or folate deficiency decreased over time. The incidence of diarrhea remained constant (63% vs 64% at five years), while the occurrence of hypomagnesemia increased (67% vs 43% at five years, P < 0.05). Nephrolithiasis occurred in 33% of patients. Hepatic fibrosis developed in 38% of patients and was progressive. Overall, after more than 10 years, 35% of patients appeared to benefit from JIB as defined by alleviation of preoperative symptoms and the development of only mild complications (vs 47% at five years). On the other hand, irreversible complications appeared to outweigh any benefit derived from the JIB in 19% (vs no patients at five years; P < 0.01). In summary, patients with JIB remain at risk for complications, particularly hepatic fibrosis, even into the late postoperative period.

A review of 20 years of jejunoileal bypass.

BACKGROUND: The long-term effects of jejunoileostomy for morbid obesity were studied 15-20 years after surgery, in 60 patients. METHODS: A total of 141 patients underwent surgery during the years 1973 to 1979. Thirty-four (24%) had had bowel continuity reestablished because of side effects. Eight (5.6%) were dead, 4 (2.8%) had emigrated, and 11 (7.8%) lived in remote areas, leaving 84 patients for follow-up. Sixty of these patients agreed to participate in the study. Seventy-seven per cent of the study population were women, with a mean age of 50 years. RESULTS: The average weight loss was 50.2 kg; only one patient had regained the preoperative weight. The average weight was 84.2 kg. Reported side effects were 1) gastrointestinal: diarrhoea (61.7%), bad defecation smells (60%), and meteorism (11.7%), and 2) systemic: arthralgia (18.3%) and symptomatic nephro/cholelithiasis (18.3%). Forty-two patients (70% of the participants) found the results acceptable/satisfactory. Nine patients (15%) had vitamin B12 injections regularly; another 22 (35%) were found to have a low cobalamin level, and 35 patients (58%) had reduced P-magnesium. The 25-hydroxycholecalciferol level was low in 26 patients (43%), parathyroid hormone values were increased in 18 (30%). Fifty-seven patients (95%) had a P-carotene value lower than the normal limit. CONCLUSION: These results stress the need for continuous control and supplementary therapy.

Reemplazos de esófago; casuística y resultados / Esophagic replacement; results and casuistical

Presentamos los resultados obtenidos en reemplazos esofágicos, ya sea por elevación retroesternal del estómago o por interpolación de diversos sectores colónicos ascendidos por la misma vía. Las operaciones mencionadas se efectuaron en enfermedades benignas y malignas luego de esofagectomía toracoabdominal total y como "by-pass" sin resección esofágica. En todos los casos la anastomosis superior fue cervical. Son 118 casos (102 cánceres, 8 megaesófagos, 5 esofagitis cústica y 3 perforaciones del esófago torácico). En dicha serie se efectuó esofagectomía toracoabdominal total por toracotomía derecha y elevación gástrica retrosternal con anastomosis esofagogástrica en el cuello en 92 oportunidades, igual resección con interpolación ileocolónica derecha en 16, usando el colon transverso en 3 y el colon izquierdo en 1 y "by-pass" retroesternal con ileocolon sin resección esofágica en 6 casos. En los enfermos portadores de enfermedades benignas (megaesófago y esofagitis caústica), no se registró mortalidad inmediata y los resultados funcionales fueron excelentes a largo plazo. En el cáncer, la mortalidad global del 20% bajó en el último quinquenio al 8%; el 60% de los enfermos llegó al año de sobrevida; el 22,5% a los 3 años y sólo el 6,8% superó los 5 años. Para alcanzar mejores resultados es absolutamente necesario lograr el diagnóstico en la etapa de cáncer temprano.

Reemplazos de esófago; casuística y resultados / Esophagic replacement; results and casuistical

Presentamos los resultados obtenidos en reemplazos esofágicos, ya sea por elevación retroesternal del estómago o por interpolación de diversos sectores colónicos ascendidos por la misma vía. Las operaciones mencionadas se efectuaron en enfermedades benignas y malignas luego de esofagectomía toracoabdominal total y como "by-pass" sin resección esofágica. En todos los casos la anastomosis superior fue cervical. Son 118 casos (102 cánceres, 8 megaesófagos, 5 esofagitis cústica y 3 perforaciones del esófago torácico). En dicha serie se efectuó esofagectomía toracoabdominal total por toracotomía derecha y elevación gástrica retrosternal con anastomosis esofagogástrica en el cuello en 92 oportunidades, igual resección con interpolación ileocolónica derecha en 16, usando el colon transverso en 3 y el colon izquierdo en 1 y "by-pass" retroesternal con ileocolon sin resección esofágica en 6 casos. En los enfermos portadores de enfermedades benignas (megaesófago y esofagitis caústica), no se registró mortalidad inmediata y los resultados funcionales fueron excelentes a largo plazo. En el cáncer, la mortalidad global del 20% bajó en el último quinquenio al 8%; el 60% de los enfermos llegó al año de sobrevida; el 22,5% a los 3 años y sólo el 6,8% superó los 5 años. Para alcanzar mejores resultados es absolutamente necesario lograr el diagnóstico en la etapa de cáncer temprano. (AU)