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Laparoscopic adjustable silicone gastric banding (LASGB) is a relatively new surgical procedure for the treatment of morbid obesity The most popular banding procedure is the vertical banded gastroplasty, however, there are risks involved in this procedure, including staple-line disruption and postoperative intractable vomiting. This article presents the advantages of using the LASGB device over former types of gastric banding.
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PMID:Laparoscopic adjustable silicone gastric banding. 1158 49

All patients who are candidates for laparoscopic fundoplication for the treatment of gastroesophageal reflux disease (GERD) should have a symptom review, barium swallow imaging, endoscopy, esophageal manometry, and ambulatory pH monitoring. The presence of a typical primary symptom, an abnormal 24-hour pH score, and a good response to acid-suppression therapy are predictive of a successful surgical outcome. The surgeon should be particularly wary of the following types of patients who may be referred for fundoplication but not have GERD: those who do not respond to proton pump inhibitors, those without esophagitis, those with only atypical symptoms, those in whom pH monitoring was done without previous manometry, and those with a borderline reflux score, severe vomiting, severe dysphagia and heartburn, unusual symptoms, severe depression, or morbid obesity.
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PMID:Preoperative evaluation of patients with gastroesophageal reflux disease. 1181 22

Severe obesity is associated with multiple comorbidities and is refractory to dietary management with or without behavioral or drug therapies. There are a number of surgical procedures for the treatment of morbid obesity, including purely gastric restrictive, a combination of malabsorption and gastric restriction or primary malabsorption. The purely gastric restrictive procedures, including vertical banded gastroplasty and laparoscopic adjustable silicone gastric banding, do not provide adequate weight loss. African-American patients do especially poorly after the banding procedure with the loss of only 11% of excess weight in one study. Gastric bypass (GBP) is associated with the loss of 66% of excess weight at 1 to 2 years after surgery, 60% at 5 years and 50% at 10 years. For unknown reasons, African-American patients lose significantly less weight than Caucasians after GBP. There is a risk of micronutrient deficiencies after GBP, including iron deficiency anemia in menstruating women, vitamin B12, and calcium deficiencies. Prophylactic supplementation of these nutrients is necessary. Recurrent vomiting after bariatric surgery may be associated with a severe polyneuropathy and must be aggressively treated with endoscopic dilatation before this complication is allowed to develop. The malabsorptive procedures include the partial biliopancreatic bypass (BPD) and BPD with duodenal switch (BPD/DS). The BPD appears to cause severe protein-calorie malnutrition in American patients; the BPD/DS may be associated with less malnutrition. Weight loss failure after GBP does not respond to tightening a dilated gastrojejunal stoma or reducing the size of the gastric pouch. These patients may require conversion to a malabsorptive distal GBP, similar to the BPD. However, because of the risk of severe protein-calorie malnutrition and calcium deficiency BPD should be reserved for patients with severe obesity comorbidity. The risk of death following bariatric surgery is between 1% and 2% in most series but is significantly higher in patients with respiratory insufficiency of obesity. In most patients, surgically induced weight loss will correct hypertension, type II diabetes mellitus, sleep apnea, obesity hypoventilation syndrome, gastroesophageal reflux, venous stasis disease, urinary incontinence, female sexual hormone dysfunction, pseudotumor cerebri, degenerative joint disease pains, as well as improved self-image and employability.
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PMID:Bariatric surgery for severe obesity. 1185 Dec 1

In the treatment of morbid obesity, simple gastric restrictive methods such as silicone adjustable gastric banding, vertical banded gastroplasty, and nonadjustable gastric banding often fail to control weight in the long run or give rise to intolerable side effects. Here we review our results from conversion of such failures to Roux-en-Y gastric bypass. The study comprised 44 patients (median age 42 years, range 24 to 60 years) who underwent revision surgery in 1996 and 1997. Body mass index at revision was 35 kg/m(2) (range 21 to 49 kg/m(2)). Previous bariatric procedures included silicone adjustable gastric banding (n = 26), vertical banded gastroplasty (n = 13), and gastric banding (n = 5). The most common reasons for conversion after silicone adjustable gastric banding and nonadjustable gastric banding were band erosion (n = 12) and esophagitis (n = 11). Staple line disruption (n = 12) with subsequent weight loss failure was the primary cause after vertical banded gastroplasty. There were no postoperative deaths or anastomotic leaks. One patient underwent reexploration because of an infected hematoma. Reflux symptoms and vomiting resolved promptly. At global assessment 2 years later, 70% of the patients were very satisfied. Median body mass index had decreased to 28 kg/m(2) (range 18 to 42 kg/m(2)). No patient was lost to follow-up. As reported previously, failure after vertical gastric banding can be treated by conversion to Roux-en-Y gastric bypass with good results. In this study we found that failure after silicone adjustable gastric banding can be treated successfully with Roux-en-Y gastric bypass as well.
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PMID:Roux-en-Y gastric bypass after previous unsuccessful gastric restrictive surgery. 1265 70

There is mounting concern that internal hernia formation after laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity remains unrecognized until complications develop. In this report we present our experience with this complication. Out of 100 patients who underwent LRYGB we identified five patients who were diagnosed with postoperative internal hernia formation. The medical records and operative details of these patients were reviewed. Of the five patients four were female and the average age was 36 years (range 30-43). All Roux limbs were placed in a retrocolic position. The average time interval to presentation was 104 days (range 4-305). All patients had abdominal pain and four patients experienced vomiting. One patient had obstipation. Only one patient had fever (38.1 degrees C) and the highest white cell count was 14,500. The average loss in body-mass index was 5.21 kg/m2 (range 2.5-14.8). Plain abdominal films revealed dilated bowel in the upper abdomen in three patients. Contrast bowel series was diagnostic in only one patient. One patient had a CT scan, which was diagnostic of small bowel obstruction. All patients underwent operative reduction of the internal hernia; two of these were completed laparoscopically. All hernias had occurred at the mesocolic window and were caused by sutures that had pulled through tissue at the dorsal and lateral aspect of the initial repair. One patient had a nonviable segment of small bowel. There were no deaths. Patients who undergo LRYGB are at a 5 per cent risk for developing small bowel obstruction secondary to internal hernia formation at the mesocolic window. Clinical evaluation and traditional study modalities may not be effective diagnostic tools. A high index of suspicion and low threshold to explore these patients may be the best way to avoid serious sequelae. Modification of operative techniques may reduce the occurrence of internal hernia formation.
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PMID:Internal hernia formation after laparoscopic Roux-en-Y gastric bypass for morbid obesity. 1213 50

The frequency of bariatric surgery has increased markedly in France in recent years, partly due to a better appreciation of the problem of morbid obesity but also due to the commercial introduction of adjustable gastric banding devices which can be placed by laparoscopic approach. Numerous complications of this surgery are known and require recognition to be appropriately treated. Studies of complications suffer from selection bias, methodologic flaws, and lack of follow-up. The incidence and type of complication are affected by the learning curve and surgical techniques. Postoperative mortality varies from 0.14% for laparoscopic gastric banding (LGB), to 0.31% for vertical banded gastroplasty (VBGP) and 0.35% for Roux-en-Y gastric bypass (GBP); pulmonary embolus accounts for 60-70% of deaths in all groups combined. Early post-operative complications vary with specific procedures. Abdominal wall complications, already frequent in an obese population, are decreased from 10% for open procedures to 6% for laparoscopic gastric banding. Both VBGP and GBP are now being done laparoscopically with increasing frequency. Complications specific to LGB include gastric perforation (0.3%), or port problems (5%). Complications with VBGP and GBP include fistula (1-3%), deep abscess, and pulmonary embolus (2%). Global early morbidity is 4.2% for LGB, and varies from 6.4%-22% for VBGP and 6.2%-11.3% for GBP depending on laparoscopic versus open approach. Late mechanical complications are also specific to type of surgery. Pouch dilatation is the most common late complication of LGB (6.3%) and seems related both to operative experience and to site of placement of the band; it has decreased with higher positioning of the band to leave a minimal gastric pouch and with dissection through the pars flaccida of the lesser omentum instead of directly along the muscular wall of the stomach. It usually requires reintervention. Erosion of the gastric band into the stomach (1.6%) is often asymptomatic and is suggested by late weight gain. With VBGP, disruption of a gastric staple line occurs in 12.1% and stenosis of the outlet with proximal dilatation in 6.5%; erosion of the calibrating band of Marlex or silastic occurs in 2.7%. With GBP, the disruption of a staple line across an intact stomach (23%) has become less of a problem with division of the gastric pouch from the distal stomach (2%). Stenosis of the gastrojejunostomy (3.7%) and marginal ulcer (3.5%) are not uncommon. The incidence of wound hernia, obstructive adhesions, and late cholecystectomy vary with the length and thoroughness of follow-up. Late functional complications such as vomiting, dysphagia, heartburn and esophagitis vary with the quality and length of follow-up study. GBP may cause diarrhea and dumping syndrome. Nutritional complications are more common with GPB than with purely restrictive procedures; iron, folate, and Vitamin B12 deficiency are the rule with GBP and require routine replacement therapy; iron deficiency has been noted even with LGB. ate death seems more related to co-morbidities than to the intervention itself. Thorough long-term follow-up study of complications is indispensable for assessment of outcomes and improvement of laparoscopic techniques. Even the less traumatic surgical approach of laparoscopic band placement should not be considered free of risk; strict adherence to pre-operative surgical indications should be maintained.
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PMID:[Surgery for morbid obesity: 2. Complications. Results of a Technologic Evaluation by the ANAES]. 1270 48

Laparoscopic Roux-en-Y (RY) gastric bypass is an effective treatment for morbid obesity. However, little information is available regarding the gastrointestinal symptomatic outcome after laparoscopic RY gastric bypass for morbid obesity. The purpose of this study is to identify changes occurring in gastrointestinal symptoms after laparoscopic RY gastric bypass. A previously validated, 19-point gastrointestinal symptom questionnaire was administered prospectively to each patient seen for surgical consultation to treat morbid obesity. Patients rated the degree to which each symptom affected their lives on a 0 to 100 mm Liekert scale with 0 indicating absence of a symptom, 33 indicating the symptom was present occasionally, 67 indicating the symptom occurred frequently, and 100 indicating the symptom was continuous. The same survey was readministered 6 months postoperatively. The mean of each symptom (preoperative vs. postoperative value) was compared using Student's t test with significance at P<0.05. Forty-three preoperative patients (age 37.3+/-8.6 years; body mass index 47.8+/-4.9) and thirty-five, 6 months' postoperative patients (81% follow-up; body mass index 31.6+/-5.3) completed the questionnaire. The result for each symptom is expressed as mean+/-standard deviation of preoperative vs. postoperative scores. Significantly different symptoms include the following: abdominal pain 23.3+/-26.4 vs. 8.6+/-13.5, P=0.003; heartburn 34.0+/-26.6 vs. 8.0+/-14.0, P=0.0001; acid regurgitation 28.1+/-24.0 vs. 10.7+/-21.0, P=0.001; gnawing in epigastrium 19.3+/-22.7 vs. 7.5+/-16.0, P=0.01; abdominal distention 38.2+/-31.5 vs. 11.1+/-19.2, P=0.0001; eructation 27.7+/-24.4 vs. 15.5+/-16.9, P=0.01; increased flatus 40.2+/-25.7 vs. 25.2+/-25.3, P=0.005; decreased stools 5.4+/-16.8 vs. 17.4+/-20.0, P=0.0005; increased stools 23.9+/-26.7 vs. 6.5+/-11.7, P=0.0005; loose stools 29.7+/-26.5 vs. 17.5+/-20.0, P=0.03; urgent defecation 34.3+/-26.5 vs. 14.3+/-19.3, P=0.0009; difficulty falling asleep 44.1+/-38.4 vs. 27.5+/-32.9, P=0.05; insomnia 42.4+/-36.2 vs. 21.6+/-30.5, P=0.008; and rested on awakening 65.1+/-33.8 vs. 30.5+/-28.8, P=0.0001. Symptoms that did not significantly change included the following: nausea/vomiting 17.2+/-22.7 vs. 22.1+/-19.9, P=0.33; borborygmus 28.8+/-25.2 vs. 26.8+/-29.7, P=0.75; hard stools 10.3+/-22.9 vs. 7.1+/-18.6, P=0.56; incomplete evacuation of stool 17.2+/-22.8 vs. 13.4+/-21.7, P=0.45; and dysphagia 10.9+/-15.6 vs. 17.7+/-28.4, P=0.18. Laparoscopic RY gastric bypass significantly improves many gastrointestinal symptoms experienced by morbidly obese patients without adversely affecting any of the measured parameters. This information is useful in preoperative counseling to assure patients of overall symptomatic improvement after this operation in addition to significant weight loss and improvement of comorbid conditions.
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PMID:Gastrointestinal symptomatic outcome after laparoscopic Roux-en-Y gastric bypass. 1312 51

Morbid obesity is associated with various disorders and may effectively be treated by restrictive surgery, such as laparoscopic adjustable gastric banding (LAGB). We observed a patient suffering from cardiac arrhythmias following LAGB. These cardiac events were likely evoked by hypokalemia due to persistent vomiting after placement of the band. We describe a case of continuing vomiting following a gastric banding procedure. Causes may include both mechanical, i.e. gastric prolapse, and psychological factors. The present case stresses the need for frequent follow-up for patients after a gastric restrictive operation.
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PMID:Cardiac arrhythmias after laparoscopic banding. 1498 51

A 20-year-old female, who had suffered from morbid obesity with a BMI of 41.2, was admitted 3 years after undergoing laparoscopic gastric banding. 3 days before her present admission, she began suffering from abdominal pain without vomiting. On admission investigation, gastric prolapse was diagnosed with complete obstruction of passage through the band. Emergency laparoscopy was performed, which showed devitalization of the stomach above the band. At the operation, the band was removed, and conservative treatment was begun with nasogastric aspiration, total parenteral nutrition, and close observation.
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PMID:Gastric wall necrosis following late prolapse after laparoscopic banding. 1498 52

A 41-year-old woman in November 2002 underwent a gastric bypass by the Capella technique for morbid obesity. Almost 1 year after the surgery, she developed severe vomiting. Radiological studies confirmed a severe stenosis of the gastrojejunal anastomosis. Two pneumatic dilatations of the stenosis failed. In February 2004, she underwent resection of the stenotic anastomosis. Histology showed an intact mucosa and beneath it an abscess filled with numerous filamentous microorganisms, with typical features of Actinomyces. With the diagnosis of gastric actinomycosis, she received a postoperative course of antibiotherapy with imipenem and was discharged after an uneventful recovery. Gastric actinomycosis is a rare infection, of which only 19 additional cases have been reported in the literature. To our knowledge, this is the first case to affect a patient following batriatric surgery. The reported cases of this entity are reviewed, and the diagnostic criteria that could avoid surgery in these cases are discussed.
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PMID:Gastric actinomycosis: a rare complication after gastric bypass for morbid obesity. 1532 95


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