Background: Laparoscopic adjustable gastric banding (GB) is the most popular restrictive procedure for obesity in Europe. Isolated sleeve gastrectomy (SG), is less common, but more invasive and with a higher learning curve. The aim of this prospective randomized study was to compare the results of GB and SG after 1 and 3 years of surgery. Methods: 80 patient candidates for laparoscopic restrictive surgery were operated consecutively and randomly, between January and December 31, 2002, by GB (7M, 33F) or by SG (9M, 31F) (NS). Median age was 36 (20-61) for GB versus 40 (22-65) for SG (NS). Median BMI was 37 (30-47) for GB versus 39 (30-53) for SG (NS). After 1 and 3 years: weight loss, feeling of hunger, sweet eating, gastroesophageal reflux disease (GERD), complications and re-operations were recorded in both groups. Results: Median weight loss after 1 year was 14 kg (−5 to +38) for GB and 26 kg (0 to 46) for SG (P<0.0001); and after 3 years was 17 kg (0 to 40) for GB and 29.5 kg (1 to 48) for SG (P<0.0001). Median decrease in BMI after 1 year was 15.5 kg/m 2 (5 to 39) after GB and 25 kg/m2 (0 to 45) after SG (P<0.0001); and after 3 years was 18 kg/m2 (0 to 39) after GB and 27.5 kg/m 2 (0 to 48) after SG (P=0.0004). Median %EWL at 1 year was 41.4% (−11.8 to +130.5) after GB and 57.7% (0 to 125.5) after SG (P=0.0004); and at 3 years was 48% (0 to 124.8) after GB and 66% (−3.1 to +152.4) after SG (P=0.0025). Loss of feeling of hunger after 1 year was registered in 42.5% of patients with GB and in 75% of patients with SG (P=0.003); and after 3 years in 2.9% of patients with GB and 46.7% of patients with SG (P<0.0001). Loss of craving for sweets after 1 year was achieved in 35% of patients with GB and 50% of patients with SG (NS); and after 3 years in 2.9% of patients with GB and 23% of patients with SG (NS). GERD appeared de novo after 1 year in 8.8% of patients with GB and 21.8% of patients with SG (NS); and after 3 years in 20.5% of patients with GB and 3.1% of patients with SG (NS). Postoperative complications requiring re-operation were necessary for 2 patients after SG. Late complications requiring re-operation after GB included 3 pouch dilations treated by band removal in 2 and 1 laparoscopic conversion to Roux-en-Y gastric bypass (RYGBP), 1 gastric erosion treated by conversion to RYGBP, and 3 disconnections of the system treated by reconnection. Inefficacy affected 2 patients after GB, treated by conversion into RYGBP and 2 patients after SG treated by conversion to duodenal switch. Conclusion: Weight loss and loss of feeling of hunger after 1 year and 3 years are better after SG than GB. GERD is more frequent at 1 year after SG and at 3 years after GB. The number of re-operations is important in both groups, but the severity of complications appears higher in SG.

A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years.

https://www.soard.org/article/S1550-7289(08)00630-8/pdf

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient.

Objective:To assess the safety and effectiveness of the laparoscopic sleeve gastrectomy (LSG) as compared to the laparoscopic adjustable gastric band (LAGB), the laparoscopic Roux-en-Y gastric bypass (LRYGB) and the open Roux-en-Y gastric bypass (ORYGB) for the treatment of obesity and obesity-relat

/pdf/first-report-from-the-american-college-of-surgeons-bariatric-5bshortkod.pdf

First Report from the American College of Surgeons -- Bariatric Surgery Center Network: Laparoscopic Sleeve Gastrectomy has Morbidity and Effectiveness Positioned Between the Band and the Bypass

/pdf/consenso-seedo-2007-para-la-evaluacion-del-sobrepeso-y-la-4k2o1e02tl.pdf

Consenso SEEDO 2007 para la evaluación del sobrepeso y la obesidad y el establecimiento de criterios de intervención terapéutica

The surgical treatment of obesity in the high-risk, high-body-mass-index (BMI) (>60) patient remains a challenge. Major morbidity and mortality in these patients can approach 38% and 6%, respectively. In an effort to achieve more favorable outcomes, we have employed a two-stage approach to such high-risk patients. This study evaluates our initial outcomes with this technique. In this study, patients underwent laparoscopic sleeve gastrectomy (LSG) as a first stage during the period January 2002–February 2004. After achieving significant weight loss and reduction in co-morbidities, these patients then proceeded with the second stage, laparoscopic Roux-en-Y gastric bypass (LRYGBP). During this time, 126 patients underwent LSG (53% female). The mean age was 49.5 ± 0.9 years, and the mean BMI was 65.3 ± 0.8 (range 45–91). Operative risk assessment determined that 42% were American Society of Anesthesiologists physical status score (ASA) III and 52% were ASA IV. The mean number of co-morbid conditions per patient was 9.3 ± 0.3 with a median of 10 (range 3–17). There was one distant mortality and the incidence of major complications was 13%. Mean excess weight after LSG at 1 year was 46%. Thirty-six patients with a mean BMI of 49.1 ± 1.3 (excess weight loss, EWL, 38%) had the second-stage LRYGBP. The mean number of co-morbidities in this group was 6.4 ± 0.1 (reduced from 9). The ASA class of the majority of patients had been downstaged at the time of LRYGB. The mean time interval between the first and second stages was 12.6 ± 0.8 months. The mean and median hospital stays were 3 ± 1.7 and 2.5 (range 2–7) days, respectively. There were no deaths, and the incidence of major complications was 8%. The staging concept of LSG followed by LRYGBP is a safe and effective surgical approach for high-risk patients seeking bariatric surgery.

https://my.clevelandclinic.org/ccf/media/Files/BMI/general-acadeamic/laparoscopic-sleeve-gastrectomy-as-an-initial-weight-loss.pdf?la=en

Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity

Background: Bariatric surgery in patients with significant co-morbid conditions is associated with increased perioperative risk. Methods: From 1995-2001, 795 patients were operated upon at our institution for the diagnosis of morbid obesity. Of these, 671 (84.4%) had the duodenal switch (DS) procedure. Longitudinal gastrectomy (LG) entails a greater curvature linear gastrectomy creating a gastric tube with a volume of 100 ml along the lesser curvature of the stomach. This procedure was performed for 21 patients (median age 50.5, median BMI 56). 9 patients were offered LG preoperatively because of their known high perioperative risks. 12 patients were initially planned for DS, but the procedure was limited to LG alone because of either unexpected intraoperative findings (n=9) or intraoperative hemodynamic instability (n=3). 5 patients developed complications, and there were no deaths. Results: 19 out of 21 patients were available for a median follow-up of 17.5 months (6.25-20.25). Median weight loss and median %EWL at 12 months were 44.5 kg and 45.1%, respectively. Estimated daily dietary volume at 1 year was 35% of preoperative values. Of 10 patients followed for ≥ 1 year, 4 of 10 achieved more than 50% EWL and 8 patients were taking less or were completely off medications for diabetes, hypertension and congestive heart failure. Weight loss plateaued at 1 year for the majority of patients. Conclusions: LG is a safe and effective option for high-risk morbidly obese patients. Weight reduction is accomplished by limitation of caloric intake. LG can be offered to high-risk morbidly obese patients as an interim procedure to help decrease perioperative risk before DS.

Longitudinal Gastrectomy as a Treatment for the High-Risk Super-Obese Patient

Background: The simultaneous occurrence of achalasia and morbid obesity is rare. Nevertheless, the surgical therapy of morbid obesity may be harmful, if undiagnosed achalasia were left untreated. We report the clinical presentation and response to treatment of achalasia in the context of morbid obesity. Methods: From 1998 to 2002, 638 patients underwent surgery for morbid obesity. Preoperative upper gastrointestinal radiography was performed in all patients. Three patients had manometric confirmation of achalasia. The characteristic symptoms were recurrent episodes of regurgitation, chronic cough and aspiration. No patient reported dysphagia or recent weight loss. Results: All patients had a duodenal switch procedure and in two a concurrent Heller myotomy was added. The other patient required a Heller myotomy after a duodenal switch had been performed, because the motility study was initially misinterpreted. All patients reported gradual resolution of presenting symptoms after myotomy. Conclusions: A careful symptomatic history focusing on aspiration, regurgitation and cough may identify the unusual combination of achalasia and morbid obesity. Treatment of morbid obesity alone may lead to progression of pulmonary symptoms.

Achalasia in the context of morbid obesity: a rare but important association

Background Current treatment options for acute calculous cholecystitis include either early cholecystectomy, or conservative treatment consisting of intravenous antibiotics and an interval cholecystectomy several weeks later. Percutaneous drainage is reserved for patients in whom conservative therapy failed or as a salvage procedure for high risk patients. Objective To identify clinical and radiographic factors leading to failure of conservative treatment. Methods We prospectively collected data on consecutive patients admitted with the diagnosis of acute cholecystitis. Parameters were compared between patients who were successfully treated conservatively and those who required percutaneous cholecystostomy. Logistic regression analysis was performed to identify predictors for failure of conservative treatment. Results The study population comprised 103 patients with a median age of 60 who were treated for acute cholecystitis. Twenty-seven patients (26.2%) required PC. On univariate analysis, age above 70 years, diabetes, elevated white blood cell count, tachycardia (> 100 beats/min) at admission, and a distended gallbladder (> 5 cm transverse diameter) were found to be significantly more common in the PC group (P Conclusions Age above 70, diabetes, and a distended gallbladder are predictors for failure of conservative treatment and such patients should be considered for early cholecystostomy. Persistently elevated WBC (> 15,000) suggests refractory disease and should play a central role in the clinical follow-up and decision-making process for elderly patients with acute cholecystitis.

Conservative treatment for acute cholecystitis: clinical and radiographic predictors of failure.

INTRODUCTION Aggressive surgical pancreatic debridement remains the standard of care, may require multiple abdominal explorations and is associated with high mortality. We have introduced the stepped technique of percutaneous treatment of infected peripancreatic fluid collections. METHODS We performed a retrospective review of patients with severe infected necrotizing pancreatitis who were managed percutaneously. Culture results, number of radiological interventions, length of stay, and complications were recorded. RESULTS There were 8 patients with a median number of Ranson's criteria of 4.5. Sixty invasive procedures were performed. A median number of two separate catheter sites per patient were necessary for the removal of necrotic material. Median duration of percutaneous intervention was 71.5 days with complete removal of necrotic material and resolution of infected collections in all patients. CONCLUSIONS Surgeons and interventional radiologists should be familiar with this evolving technique which is less invasive then surgery, but may prolong the time necessary for complete resolution.

Percutaneous "stepped" drainage technique for infected pancreatic necrosis.

The incidence of geriatric trauma is rising with an increased life expectancy and a more active lifestyle among the elderly. The aim of this study was to describe the different patterns of injury with increased age in severely injured elderly patients and to identify predictors of in-hospital mortality.

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Gidon Almogy

Papers

Longitudinal Gastrectomy as a Treatment for the High-Risk Super-Obese Patient

Achalasia in the context of morbid obesity: a rare but important association

Conservative treatment for acute cholecystitis: clinical and radiographic predictors of failure.

Percutaneous "stepped" drainage technique for infected pancreatic necrosis.

Pre-hospital and admission parameters predict in-hospital mortality among patients 60 years and older following severe trauma.