Prevalence of peri-intubation major adverse events among critically ill patients: A systematic review and meta analysis.

BACKGROUND: Peri-intubation major adverse events (MAEs) are potentially preventable and associated with poor patient outcomes. Critically ill patients intubated in Emergency Departments, Intensive Care Units or medical wards are at particularly high risk for MAEs. Understanding the prevalence and risk factors for MAEs can help physicians anticipate and prepare for the physiologically difficult airway. METHODS: We searched PubMed, Scopus, and Embase for prospective and retrospective observational studies and randomized control trials (RCTs) reporting peri-intubation MAEs in intubations occurring outside the operating room (OR) or post-anesthesia care unit (PACU). Our primary outcome was any peri-intubation MAE, defined as any hypoxia, hypotension/cardiovascular collapse, or cardiac arrest. Esophageal intubation and failure to achieve first-pass success were not considered MAEs. Secondary outcomes were prevalence of hypoxia, cardiac arrest, and cardiovascular collapse. We performed random-effects meta-analysis to identify the prevalence of each outcome and moderator analyses and meta-regressions to identify risk factors. We assessed studies' quality using the Cochrane Risk of Bias 2 tool and the Newcastle-Ottawa Scale. RESULTS: We included 44 articles and 34,357 intubations. Peri-intubation MAEs were identified in 30.5% of intubations (95% CI 25-37%). MAEs were more common in the intensive care unit (ICU; 41%, 95% CI 33-49%) than the Emergency Department (ED; 17%, 95% CI 12-24%). Intubation for hemodynamic instability was associated with higher rates of MAEs, while intubation for airway protection was associated with lower rates of MAEs. Fifteen percent (15%, 95% CI 11.5-19%) of intubations were complicated by hypoxia, 2% (95% CI 1-3.5%) by cardiac arrest, and 18% (95% CI 13-23%) by cardiovascular collapse. CONCLUSIONS: Almost one in three patients intubated outside the OR and PACU experience a peri-intubation MAE. Patients intubated in the ICU and those with pre-existing hemodynamic compromise are at highest risk. Resuscitation should be considered an integral part of all intubations, particularly in high-risk patients.

Success Rates with Digital Intubation: Comparing Unassisted, Stylet, and Gum-Elastic Bougie Techniques.

INTRODUCTION: The utility of digital intubation, especially in an austere environment with limited equipment, has been previously described. However, evidence supporting best practices for its technique is limited. We seek to quantify the time to intubation and the rate of successful placement of the tube for digital intubation using different approaches and assistance devices. METHODS: Using a manikin, digital intubation was performed with an endotracheal tube alone, with an endotracheal tube and a 14-French stylet, or with a gum-elastic bougie. All 3 techniques were performed in a crossover fashion at the manikin's side and head. Three trials per technique and position were performed. Outcomes measured were the time to intubation and the successful placement of the tube. RESULTS: A total of 72 timed trials were performed. A significant difference did not exist between practitioners being positioned at the head vs side in terms of time or successful placement rate. There was no difference between the time to intubation in the tube-only and stylet-assisted groups, but the bougie-assisted group was significantly slower than the others. The stylet-assisted technique was significantly more successful than the other 2 techniques. CONCLUSIONS: In a manikin model, stylet-assisted digital intubation was the most successful technique tested and allowed intubation to be accomplished just as quickly as with an endotracheal tube alone. Bougie-assisted digital intubation was slower and may not be as helpful as when it is used as an adjunct with direct laryngoscopy. Further research is needed to determine the utility of these adjuncts on live subjects.

Does a preoperative medically supervised weight loss program improve bariatric surgery outcomes? A pilot randomized study.

BACKGROUND: Many insurance payors mandate that bariatric surgery candidates undergo a medically supervised weight management (MSWM) program as a prerequisite for surgery. However, there is little evidence to support this requirement. We evaluated in a randomized controlled trial the hypothesis that participation in a MSWM program does not predict outcomes after laparoscopic adjustable gastric banding (LAGB) in a publicly insured population. METHODS: This pilot randomized trial was conducted in a large academic urban public hospital. Patients who met NIH consensus criteria for bariatric surgery and whose insurance did not require a mandatory 6-month MSWM program were randomized to a MSWM program with monthly visits over 6 months (individual or group) or usual care for 6 months and then followed for bariatric surgery outcomes postoperatively. Demographics, weight, and patient behavior scores, including patient adherence, eating behavior, patient activation, and physical activity, were collected at baseline and at 6 months (immediately preoperatively and postoperatively). RESULTS: A total of 55 patients were enrolled in the study with complete follow-up on 23 patients. Participants randomized to a MSWM program attended an average of 2 sessions preoperatively. The majority of participants were female and non-Caucasian, mean age was 46 years, average income was less than $20,000/year, and most had Medicaid as their primary insurer, consistent with the demographics of the hospital's bariatric surgery program. Data analysis included both intention-to-treat and completers' analyses. No significant differences in weight loss and most patient behaviors were found between the two groups postoperatively, suggesting that participation in a MSWM program did not improve weight loss outcomes for LAGB. Participation in a MSWM program did appear to have a positive effect on physical activity postoperatively. CONCLUSION: MSWM does not appear to confer additional benefit as compared to the standard preoperative bariatric surgery protocol in terms of weight loss and most behavioral outcomes after LAGB in our patient population.

The effectiveness of adjustable gastric banding: a retrospective 6-year U.S. follow-up study.

BACKGROUND: This study aimed to assess the efficacy of laparoscopic adjustable gastric banding (LAGB) during a 6-year follow-up period. METHODS: A retrospective database analysis of patients who underwent LAGB at New York University Medical Center between 1 January 2000 and 29 February 2008 was conducted. Patients were included for the efficacy analysis if they were 18 years old or older at the surgery date and had one or more visits with a recorded weight after surgery. Efficacy was assessed using percentage of excess weight loss (%EWL) at 1-year intervals after surgery. Missing weight values were interpolated using a cubic spline function. Linear regression models were used to assess the characteristics that affected the last available %EWL. All patients had implantation of the LAP-BAND system. RESULTS: The inclusion criteria for the efficacy analysis were met by 2,909 patients. The majority of the patients were white (83.3%) and female (68.4%). The mean patient age was 44.6 years, and the mean baseline body mass index (BMI) was 45.3 kg/m2. The %EWL 3 years after surgery was 52.9%, which was sustained thereafter. In multivariate models, increased number of office visits, younger age, female gender, and Caucasian race were significantly associated with a higher maximum %EWL. CONCLUSIONS: The LAP-BAND patients achieved a substantial and sustainable weight loss of approximately 50% at 6 years after surgery.

Safety of the laparoscopic adjustable gastric band: 7-year data from a U.S. center of excellence.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) has become one of the most common weight-loss procedures performed in the United States. The authors' high-volume academic medical center has gathered a database of almost 3,000 patients who have undergone LAGB since January 2001. The goal of this series, the largest to date on LAGB outcomes at a single institution, was to assess complications associated with LAGB. METHODS: A retrospective analysis was performed using longitudinal data from adult patients who underwent LAGB between 1 January 2001, and 29 February 2008. General and band-related complications were reported for all patients. Death and reoperation for weight gain (LAGB followed by either a second band insertion or a gastric bypass) also were reported. RESULTS: Of the 2,965 patients who received LAGB during the study period, 2,909 met the criteria for inclusion in this analysis, and 363 (12.2%) experienced one or more complications. The most common complications were band slip (4.5%) and port-related problems (3.3%). Other complications were rare. Only seven patients (0.2%) had band erosion. Eleven patients (0.4%) underwent reoperation for weight gain. A total of 10 deaths (0.34%) occurred during the study period. Three patients died within 30 days of surgery. Two of these deaths (0.06%) were related to surgery, and one resulted from a motor vehicle accident. Seven patients died of causes unrelated to surgery during the course of the study. CONCLUSIONS: The LAGB technique is a relatively safe procedure with few early or late complications. Few LAGB patients undergo reoperation for weight gain, and mortality is very rare.

Early U.S. outcomes after laparoscopic adjustable gastric banding in patients with a body mass index less than 35 kg/m2.

BACKGROUND: Many mildly to moderately obese individuals with a body mass index (BMI) lower than 35 kg/m(2) have serious diseases related to their obesity. Nonsurgical therapy is ineffective in the long term, yet surgery has never been made widely available to this population. METHODS: Between 2002 and 2007, 53 patients with a BMI lower than 35 kg/m(2) underwent laparoscopic adjustable gastric banding at our institution. Data on all these patients were collected prospectively and entered into an institutional review board-approved electronic registry. The study parameters included preoperative age, gender, BMI, presence of comorbidities, percentage of excess weight loss (%EWL), and resolution of comorbidities. RESULTS: The mean preoperative age of the patients was 46.9 years (range, 16-68 years), and the mean preoperative BMI was 33.1 kg/m(2) (range, 28.2-35.0 kg/m(2)). Of the 53 patients, 49 (92%) had at least one obesity-related comorbidity. The mean BMI decreased to 28.1 +/- 2.4 kg/m(2), 25.8 +/- 2.9 kg/m(2), and 25.8 +/- 3.1 kg/m(2) and mean %EWL was 48.3 +/- 17.6, 69.9 +/- 28.0, and 69.7 +/- 31.7 at 0.5, 1, and 2 years, respectively. Substantial improvement occurred for the following comorbidities evaluated: hypertension, depression, diabetes, asthma, hypertriglyceridemia, obstructive sleep apnea, hypercholesterolemia, and osteoarthritis. There was one slip, two cases of band obstruction (from food), two cases of esophagitis, and two port leaks, but no mortality. CONCLUSION: The authors are very encouraged by this series of low-BMI patients who underwent laparoscopic adjustable gastric banding. Their weight loss has been excellent, and their complications have been acceptable. Their comorbidities have partially or wholly resolved. With further study, it is reasonable to expect alteration of the weight guidelines for bariatric surgery to include patients with a BMI lower than 35 kg/m(2).

The effect of laparoscopic gastric banding surgery on plasma levels of appetite-control, insulinotropic, and digestive hormones.

BACKGROUND: We hypothesized that laparoscopic adjustable gastric banding (LAGB) reduces weight and modulates ghrelin production, but largely spares gastrointestinal endocrine function. To examine this hypothesis, we determined plasma concentrations of appetite-control, insulinotropic, and digestive hormones in relation to LAGB. METHODS: Twenty-four patients undergoing LAGB were prospectively enrolled. Body mass index (BMI) was measured and blood samples obtained at baseline and 6 and 12 months post-surgery. Plasma concentrations of leptin, acylated and total ghrelin, pancreatic polypeptide (PP), insulin, glucose-dependent insulinotropic peptide (GIP), active glucagon-like peptide-1 (GLP-1), gastrin, and pepsinogens I and II were measured using enzyme-linked immunoassays. RESULTS: Median percent excess weight loss (%EWL) over 12 months was 45.7% with median BMI decreasing from 43.2 at baseline to 33.8 at 12 months post-surgery (p < 0.001). Median leptin levels decreased from 19.7 ng/ml at baseline to 6.9 ng/ml at 12 months post-surgery (p < 0.001). In contrast, plasma levels of acylated and total ghrelin, PP, insulin, GIP, GLP-1, gastrin, and pepsinogen I did not change in relation to surgery (p > 0.05). Pepsinogen II levels were significantly lower 6 months after LAGB but returned to baseline levels by 12 months. CONCLUSIONS: LAGB yielded substantial %EWL and a proportional decrease in plasma leptin. Our results support the hypothesis that LAGB works in part by suppressing the rise in ghrelin that normally accompanies weight loss. Unchanged concentrations of insulinotropic and digestive hormones suggest that gastrointestinal endocrine function is largely maintained in the long term.

Hiatal hernia repair at the initial laparoscopic adjustable gastric band operation reduces the need for reoperation.

BACKGROUND: Intractable reflux, either due to gastric prolapse or concentric pouch dilatation has been the most common indication for reoperation or band removal after laparoscopic adjustable gastric banding (LAGB). We have previously found that a simple hiatal hernia repair (HHR) leads to remission of these symptoms minimizing the need for band removal. We have subsequently added crural repair/HHR at the initial operation, where indicated. In this study compare the rate of reoperation in patients who underwent LAGB alone, or with concurrent HHR. METHODS: A retrospective review of a prospective database of all patients undergoing LAGB was performed to determine the incidence of reoperation in the two groups. RESULTS: Between July 2001 and August of 2006, 1298 patients underwent LAGB and 520 patients underwent LAGB with concurrent HHR (LAGB/HHR). The mean initial weight and BMI were 128 kg (range, 71.1-245.7 kg) and 45.4 kg/m(2) (range, 28-75 kg/m(2)). Average follow-up for the LAGB and LAGB/HHR groups was 24.8 and 20.5 months, respectively. Rate of reoperation for HHR alone, or with band slip or concentric pouch dilatation, for LAGB and LAGB/HHR groups was 5.6% and 1.7% respectively (p < 0.001). Total reoperation rate for slip, HHR and pouch dilatation was 7.9% and 3.5%, respectively (p < 0.001). There was no significant difference in rate of slip repair alone between the two groups: 2.3% and 1.7%, respectively (p < 0.44). CONCLUSIONS: Adding HHR to LAGB where indicated significantly reduces reoperation rate. Every effort should be made to detect and repair HHR during placement of the band, as it will decrease future need for reoperation.

Gastric banding as a salvage procedure for patients with weight loss failure after Roux-en-Y gastric bypass.

BACKGROUND: This study reviews outcomes after laparoscopic adjustable gastric band (LAGB) placement in patients with weight loss failure after Roux-en-Y gastric bypass (RYGBP). METHODS: All data was prospectively collected and entered into an electronic registry. Characteristics evaluated for this study included pre-operative age and body mass index (BMI), gender, conversion rate, operative (OR) time, length of stay (LOS), percentage excess weight loss (EWL), and postoperative complications. RESULTS: 11 patients (seven females, four males) were referred to our program for weight loss failure after RYGBP (six open, five laparoscopic). Mean age and BMI pre-RYGBP were 39.5 years (24-58 years) and 53.2 kg/m(2) (41.2-71 kg/m(2)), respectively. Mean EWL after RYGBP was 38% (19-49%). All patients were referred to us for persistent morbid obesity due to weight loss failure or weight regain. The average time between RYGBP and LAGB was 5.5 years (1.8-20 years). Mean age and BMI pre-LAGB were 46.1 years (29-61 years) and 43.4 kg/m(2) (36-57 kg/m(2)), respectively. Vanguard (VG) bands were placed laparoscopically in most patients. There was one conversion to open. Mean OR time and LOS were 76 minutes and 29 hours, respectively. The 30-day complication rate was 0% and mortality was 0%. There were no band slips or erosions; however, one patient required reoperation for a flipped port. The average follow-up after LAGB was 13 months (2-32 months) with a mean BMI of 37.1 kg/m(2 )(22.7-54.5 kg/m(2)) and an overall mean EWL of 59% (7-96%). Patients undergoing LAGB after failed RYGBP lost an additional 20.8% EWL (6-58%). CONCLUSION: Our experience shows that LAGB is a safe and effective solution to failed RYGBP.

Treatment with lavender aromatherapy in the post-anesthesia care unit reduces opioid requirements of morbidly obese patients undergoing laparoscopic adjustable gastric banding.

BACKGROUND: Parenteral administration of opioids and NSAIDs has been the mainstay for postoperative pain control in patients undergoing laparoscopic adjustable gastric banding (LAGB). Both classes of drugs, however, are associated with serious adverse effects. An addition of complimentary analgesic techniques may decrease requirement for traditional analgesics, thus reducing the incidence of side-effects. We designed the study to evaluate the effectiveness of Lavender aromatherapy in reducing opioid requirements after LAGB. METHODS: A prospective randomized placebo controlled study was carried out on 54 patients undergoing LAGB. Upon arrival to the post-anesthesia care unit (PACU), patients in the study group were treated with lavender oil, which was applied to the oxygen face mask; the control group patients received nonscented baby oil. Postoperative pain was treated with morphine. Numerical rating scores (0-10) were used to measure the level of pain at 5, 30, and 60 min. Sedation was evaluated using the Observer Assessment of Alertness/Sedation scale (0-5). Data analyzed included the amount of opioids, NRS, OAA/S, PACU discharge time, as well as the incidence of side-effects. RESULTS: The two groups were comparable with regard to patient characteristics, intraoperative drug use, and surgical time. Significantly more patients in the Placebo group (PL) required analgesics for postoperative pain (22/27, 82%) than patients in the Lavender group (LAV) (12/26, 46%) (P = .007). Moreover, the LAV patients required significantly less morphine postoperatively than PL patients: 2.38 mg vs 4.26 mg, respectively (P = .04). There were no differences in the requirements for post-operative antiemetics, antihypertensives, or PACU discharge time. CONCLUSIONS: Our results suggest that lavender aromatherapy can be used to reduce the demand for opioids in the immediate postoperative period. Further studies are required to assess the effect of this therapy on clinically meaningful outcomes, such as the incidence of respiratory complications, delayed gastric emptying, length of hospital stay, or whether this therapy is applicable to other operations.

Glucose Metabolism After Gastric Banding and Gastric Bypass in Individuals With Type 2 Diabetes: Weight Loss Effect.

OBJECTIVE: The superior effect of Roux-en-Y gastric bypass (RYGB) on glucose control compared with laparoscopic adjustable gastric banding (LAGB) is confounded by the greater weight loss after RYGB. We therefore examined the effect of these two surgeries on metabolic parameters matched on small and large amounts of weight loss. RESEARCH DESIGN AND METHODS: Severely obese individuals with type 2 diabetes were tested for glucose metabolism, ß-cell function, and insulin sensitivity after oral and intravenous glucose stimuli, before and 1 year after RYGB and LAGB, and at 10% and 20% weight loss after each surgery. RESULTS: RYGB resulted in greater glucagon-like peptide 1 release and incretin effect, compared with LAGB, at any level of weight loss. RYGB decreased glucose levels (120 min and area under the curve for glucose) more than LAGB at 10% weight loss. However, the improvement in glucose metabolism, the rate of diabetes remission and use of diabetes medications, insulin sensitivity, and ß-cell function were similar after the two types of surgery after 20% equivalent weight loss. CONCLUSIONS: Although RYGB retained its unique effect on incretins, the superiority of the effect of RYGB over that of LAGB on glucose metabolism, which is apparent after 10% weight loss, was attenuated after larger weight loss.

Fatal complications of bariatric surgery.

BACKGROUND: Bariatric surgery is an increasingly used method to treat morbid obesity. The mortality rate among patients undergoing bariatric operations is generally quoted as between 0.05-2.0%. Our focus was not on mortality rates but rather on the reasons patients die following the procedures. In New York City, deaths that are due to predictable complications of appropriate therapy are certified as therapeutic complications. METHODS: We retrospectively reviewed all deaths investigated by the Office of the Chief Medical Examiner in New York City between 1997 and 2005 in which bariatric surgery had been performed. We report the fatal complications, the interval between surgery and death, the type of procedure, and coexisting morbidities. RESULTS: Autopsies were performed on 95% of these fatalities. There were 97 deaths due to therapeutic complications of the operations. The interval between the initial surgery and death ranged from several hours to years. The most common complication was an anastomotic leak with subsequent infection. A high percentage of deaths occurred after discharge (40%) and/or >30 days after surgery (37%). There were 8 deaths from complications of bariatric surgery that occurred >1 year after surgery. CONCLUSIONS: Studies that report the mortality rate during hospitalization or within 30 days of surgery, underestimate the actual incidence. Bariatric surgery carries both short- and long-term risks.

Objective comparison of complications resulting from laparoscopic bariatric procedures.

BACKGROUND: Several surgical treatment options for morbid obesity exist. Currently, there are no studies that objectively compare complication rates after laparoscopic bariatric operations performed at a single institution. We objectively classify and compare complications resulting from laparoscopic adjustable gastric banding (LABG), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion (BPD) with duodenal switch (DS). STUDY DESIGN: A retrospective review of a prospective database of all patients undergoing laparoscopic bariatric operation was performed. Complications were categorized according to severity score using a well-described classification system and compared between procedures. RESULTS: From September 2000 to July 2003, 780 laparoscopic bariatric operations were performed: 480 LAGB, 235 RYGB, and 65 BPD+/-DS. There was one late death. Total complication rates were: 9% for LAGB, 23% for RYGB, and 25% for BPD+/-DS. Complications resulting in organ resection, irreversible deficits, and death (grades III and IV) occurred at rates of 0.2% for LAGB, 2% for RYGB, and 5% for BPD+/-DS. LAGB group had a statistically significant lower overall complication rate, both by incidence and severity, as compared with other groups (p < 0.001). After controlling for differences of admission body mass index, gender, and race, the LAGB group had an almost three and a half times lower likelihood of a complication compared with the RYGB group (odds ratio, 3.4; 95% CI, 2.2-5.3, p < 0.001) and had an over three and a half times lower likelihood of a complication compared with the BPD with DS group (odds ratio, 3.6; 95% CI, 1.8-7.1, p < 0.001). There was no statistically significant difference between complication rates of RYGB and BPD+/-DS. CONCLUSIONS: Bariatric operation complication rates range from 9% to 25%; very few complications are serious. Laparoscopic adjustable gastric banding is the safest operation in terms of complication rate and severity when compared with laparoscopic Roux-en-Y gastric bypass or laparoscopic malabsorptive operations.

Comparison of outcomes after laparoscopic adjustable gastric banding in African-Americans and whites.

BACKGROUND: Race may affect outcomes after bariatric surgery. This study compares outcomes in terms of weight loss and comorbidity resolution between African-Americans and whites after laparoscopic adjustable gastric banding (LAGB). METHODS: Data from 959 patients undergoing LAGB between July 2001 and July 2004 were prospectively collected and entered into an electronic registry. Propensity score matching analysis was used to match whites to African-Americans on the basis of age, gender, and preoperative body mass index (BMI). Preoperative comorbidities (diabetes, hypertension, obstructive sleep apnea, hypercholesterolemia, and hypertriglyceridemia) were also compared. Operative time (OR), length of stay (LOS), comorbidity resolution, and percent excess weight loss (%EWL) at 1, 2, and 3 years were analyzed. All data were updated through May 2006. RESULTS: A total of 65 white LAGB patients were matched to 58 African-American LAGB patients on the basis of age, gender, and preoperative BMI. The preoperative mean age and BMI were 37 +/- 19 years and 47 +/- 7 kg/m2, respectively. A total of 55% of the white group and 64% of the African-American group had one or more comorbidities (P = NS). Median OR time and LOS were similar in both groups: 50 minutes and 23 hours, respectively. The majority of patients in both groups had major improvement or resolution of one or more comorbidities (61% whites vs 77% African-Americans, P = NS). There was, however, a significant difference in %EWL between whites and African-Americans at each time interval (49% vs 39% at 1 year; 55% vs 44% at 2 years; 52% vs 41% at 3 years; P < .05 for all values.). CONCLUSION: Despite the disparity in weight loss with the LAGB in African-Americans and whites, both patient populations experienced a similar improvement/resolution of obesity-related comorbidities.

Factors influencing patient choice for bariatric operation.

BACKGROUND: No study has surveyed the factors that influence morbidly obese patients' preference for a particular bariatric operation. METHOD: 469 consecutive patients in 2 major bariatric surgery centers in the United States (US, 124) and Australia (AU, 345) were prospectively studied to determine referral pattern and reason for their choice of operation. RESULTS: The predominant operation was laparoscopic adjustable gastric banding (LAGB) in both US (75%) and AU (83%) centers. Gender (70% female), BMI (45 kg/m2) and age (42.5 years) were similar in both cohorts. In Australia, 53% had referral initiated by primary doctors and 25% by another patient, while in the US, 43% by another patient and 27% by the Internet. Safety of the operation (43%) was the highest-rated factor in choosing LAGB. LAGB being "least invasive" was most significant in the US (46%), and "surgical safety" in Australia (45%). In the US, Rouxen-Y gastric bypass was preferred due to "lack of a foreign body" (31%) and "inability to cheat" (28%), while in Australia, "dumping" was the most significant reason (50%). Duodenal switch (BPD/DS) was selected in 11% of patients, primarily because of "durability of the weight loss" (51%). Surprisingly, only 1 patient in the US group selected BPD/DS because the pylorus remains intact. CONCLUSION: Safety and invasiveness had the greatest impact on patient choice for bariatric operation in two different countries. This information may help clinicians better understand their patients' concerns, and their treatment choices.

Laparoscopic bariatric surgery in super-obese patients (BMI>50) is safe and effective: a review of 332 patients.

BACKGROUND: Bariatric surgery in super-obese patients (BMI >50 kg/m(2)) can be challenging because of difficulties in exposure of visceral fat, retracting the fatty liver, and strong torque applied to instruments, as well as existing co-morbidities. METHODS: A retrospective review of super-obese patients who underwent laparoscopic adjustable gastric banding (LAGB n=192), Roux-en-Y gastric bypass (RYGBP n=97), and biliopancreatic diversion with/without duodenal switch (BPD n= 43), was performed. 30 day peri-operative morbidity and mortality were evaluated to determine relative safety of the 3 operations. RESULTS: From October 2000 through June 2004, 331 super-obese patients underwent laparoscopic bariatric surgery, with mean BMI 55.3 kg/m(2). Patients were aged 42 years (13-72), and 75% were female. When categorized by operation (LAGB, RYGBP, BPD), the mean age, BMI and gender were comparable. 6 patients were converted to open (1.8%). LAGB had a 0.5%, RYGBP 2.1% and BPD 7.0% conversion rate (P=0.02, all groups). Median operative time was 60 min for LAGB, 130 min for RYGBP and 255 min for BPD (P<0.001, all groups). Median length of stay was 24 hours for LAGB, 72 hours for RYGBP, and 96 hours for BPD (P <0.001). Mean %EWL for the LAGB was 35.3+/-12.6, 45.8+/-19.4, and 49.5+/-18.6 with follow-up of 87%, 76% and 72% at 1, 2 and 3 years, respectively. Mean %EWL for the RYGBP was 57.7+/-15.4, 54.7+/-21.2, and 56.8+/-21.1 with follow-up of 76%, 33% and 54% at 1, 2 and 3 years, respectively. Mean %EWL for the BPD was 60.6+/-15.9, 69.4+/-13.0 and 77.4+/-11.9 with follow-up of 79%, 43% and 47% at 1, 2 and 3 years, respectively. The difference in %EWL was significant at all time intervals between the LAGB and BPD (P<0.004). However, there was no significant difference in %EWL between LAGB and RYGBP at 2 and 3 years. Overall perioperative morbidity occurred in 27 patients (8.1%). LAGB had 4.7% morbidity rate, RYGBP 11.3%, and BPD 16.3% (P=0.02, all groups). There were no deaths. CONCLUSION: Laparoscopic bariatric surgery is safe in super-obese patients. LAGB, the least invasive procedure, resulted in the lowest operative times, the lowest conversion rate, the shortest hospital stay and the lowest morbidity in this high-risk cohort of patients. Rates of all parameters studied increased with increasing procedural complexity. However, the difference in %EWL between RYGBP and LAGB at 2 and 3 years was not statistically significant.

Laparoscopic adjustable gastric band.

Only a fraction of morbidly obese patients have come forward for bariatric surgery. This article confirms that the laparoscopic adjustable gastric band (LAGB) is a safe, effective, primary weight-loss operation for morbidly obese patients. The LAGB offers a simple, genuinely minimally invasive approach, with the potential to be attractive to many more patients. The key questions are whether it is effective in the longterm and whether it is safe. The midterm data confirm that, so far, LAGB is living up to its early promise as an effective tool. LAGB surgery is safe, and the change to the pars-flaccida approach will lead to even higher patient satisfaction and lower incidence of band removal.

Removal of peri-gastric fat prevents acute obstruction after Lap-Band surgery.

BACKGROUND: Acute postoperative gastroesophageal obstruction is a potential complication after laparoscopic adjustable gastric banding (LAGB). Utilizing the pars flaccida technique may increase the incidence due to the incorporation of perigastric fat, particularly in patients with greater visceral obesity. Removal of peri-gastric fat pads may be necessary to avoid postoperative obstruction. We present our experience of 267 LAGB operations using the LapBand System and the incidence of postoperative obstruction, before and after incorporating routine removal of peri-gastric fat pads. METHODS: A retrospective review of a prospective database of 267 consecutive Lap-Band placements between July 2001 and November 2002 was conducted. RESULTS: All operations were completed laparoscopically using the pars flaccida technique, and all patients underwent esophagogram the morning after surgery. From July 2001 to May 2002, 143 Lap-Band placements were performed, with 11 patients (8%) having abnormal postoperative esophagograms. There were 43 males/100 females with mean BMI 48.3 (range 35 to 78.9). Complete esophageal obstruction was seen in 5 of these patients, all of whom underwent laparoscopic revision. Significantly delayed emptying was seen in the 6 remaining patients, who were managed conservatively with intravenous fluids from 2-7 days. In these 11 patients, there were 6 males/5 females with mean BMI 47.1 (range 37.3-57.9). Subsequently, removal of peri-gastric fat pads was routinely performed during Lap-Band placement. From June 2002 to November 2002, there were 43 males/81 females with mean BMI 48 (range 35-79); these 124 Lap-Band placements were performed with no abnormal postoperative esophagograms. CONCLUSION: Routine removal of peri-gastric fat pads when using the pars flaccida technique for Lap Band surgery appears to prevent postoperative esophageal obstruction.

Radiologic assessment of the upper gastrointestinal tract: does it play an important preoperative role in bariatric surgery?

BACKGROUND: The role of upper GI series (UGIS) before bariatric surgery is controversial. The aim of this study was to evaluate the diagnostic yield and cost of routine UGIS prior to bariatric surgery. METHODS: The medical records of consecutive obese patients who underwent UGIS before bariatric surgery between April 2001 and October 2002 were reviewed. UGIS reports were reviewed by 2 experienced gastroenterologists, and the findings were divided into 4 groups based on predetermined criteria: group 0 (normal study), group 1 (abnormal findings that neither changed the surgical approach nor postponed surgery), group 2 (abnormal findings that changed the surgical approach or postponed surgery), and group 3 (results which were an absolute contraindication to surgery). Clinically important findings included lesions in groups 2 and 3. The cost of an upper GI series (154.80 USD) was estimated from the published 2002 New York State Medicare reimbursement schedule. RESULTS: During the 18-month study period, 171 patients were evaluated by UGIS prior to bariatric surgery. One or more lesions were identified in 48.0% of patients, with only 5.3% having clinically important findings. The prevalence of radiologic findings using the classification system above was as follows: group 0 (52.0%), group 1 (42.7%), group 2 (5.3%), and group 3 (0.0%). The most common findings identified were esophageal reflux (21.6%) and hiatal hernias (18.7%). The cost of performing routine UGIS on all patients before bariatric surgery was 2,941.20 USD per clinically important finding detected. CONCLUSIONS: Routine preoperative upper GI series before bariatric surgery had a low diagnostic yield, rarely revealing pathology that changed the surgical approach or postponed surgery.

Impact of patient follow-up on weight loss after bariatric surgery.

BACKGROUND: Postoperative follow-up after bariatric surgery is important. Because of the need for adjustments, follow-up after gastric banding may have a greater impact on weight loss than after Roux-en-Y gastric bypass. We reviewed all patients at 1 year after these two operations. METHODS: During the first year after surgery, laparoscopic adjustable gastric banding (LAGB) patients were followed every 4 weeks and Roux-en-Y gastric bypass (RYGBP) patients were followed at 3 weeks postoperatively and then every 3 months. The number of follow-up visits for each patient was calculated, and 50% compliance for follow-up and weight loss was compared. RESULTS: Between October 2000 and September 2002, 216 LAGB and 139 RYGBP operations were performed. Of these patients, 186 LAGB patients and 115 RYGBP patients were available for 1-year follow-up. Age and BMI were similar for each group. Overall excess weight loss (EWL) after LAGB was 44.5%. 130 (70%) returned 6 or less times in the first year and achieved 42% EWL. 56 patients (30%) returned more than 6 times and had 50% EWL (P=0.005). Overall %EWL after RYGBP was 66.1%. 53 patients (46%) returned 3 or less times in the first year, achieving 66.1% EWL. 62 patients (54%) returned more than 3 times after surgery and achieved 67.6% EWL (P=NS). CONCLUSION: Patient follow-up plays a significant role in the amount of weight lost after LAGB, but not after RYGBP. Patient motivation and surgeon commitment for long-term follow-up is critical for successful weight loss after LAGB surgery.