[The biliointestinal bypass: a thirty-years experience]. / Il bypass bilio-intestinale. Un'esperienza italiana trentennale.

AIM: Aim of our study was the evaluation of Italian experience with bilio-intestinal bypass in the surgical treatment of morbid obesity. MATERIALS AND METHODS: 1030 patients; mean age 36.1 years; preoperative mean weight Kg 136.7; mean preoperative BMI 48.9 kg/m2; mean follow-up 68 years (1-28). 838 patients underwent open and 192 laparoscopic bilio-intestinal bypass. The laparoscopy operation was performed with five lap ports. Section of the jejunum 30 cm from the Treitz was made by linear stapler. The cholecysto-jejunal anastomosis was completed with 45 mm linear stapler. A side-to-side anastomosis between the proximal jejunum and the last 12-18 cm of the ileum was created by firing a 60 mm linear stapler. RESULTS: Weight loss was satisfactory in 93% of operated patients. Comorbidities (arterial hypertension, diabetes, sleep apnea syndrome) solved in majority of the patients. The main late complications were incisional hernia in open technique and oxalic nephrolithiasis. The reversal rate was 2.5%. CONCLUSION: Our experience showed that bilio-intestinal bypass can obtain good results. Using laparoscopic technique it is possible to reduce pain, in-hospital time, respiratory and thromboembolic complications, convalescence and incisional hernia.

The bilio-intestinal bypass.

BACKGROUND: Since 1990 we adopted the bilio-intestinal bypass (BIBP) for all morbid obese patients eligible to a malabsorption procedure. Since 2001 we used laparoscopic technique. MATERIALS AND METHODS: 102 patients; mean age 35.4 (18-54) years; preoperative mean weight Kg 148.3 (105-225); mean preoperative BMI 54.1 kg/m2 (40-66.2); mean follow-up 10 years (1-22). 83 patients underwent open and 19 laparoscopic BIBP. The operation was performed with five lap ports. Section of the jejunum 30 cm from the Treitz and of mesentery was made by linear stapler. The cholecysto-jejunal anastomosis was completed with 45 mm linear stapler. A side-to-side anastomosis between the proximal jejunum and the last 12-18 cm of the ileum was created by firing a 60 mm linear stapler. On the excluded ileum an anti-reflux valve system was hand-sutured. RESULTS: Five years post-operatively mean weight was 89 (62-130) kg, mean BMI was 31 (24-41) kg/m2. Two patients of the 19 laparoscopic patients were converted in open surgery for adhesions post-appendectomy. The main late complications were incisional hernia (19.3%) and abdominal bloating (2.9%). The reversal and conversion rate was 65%. There was no death. CONCLUSION: Our experience showed that five years post-BIBP the weight loss was satisfactory in 90.7% of patients. Using laparoscopic technique it is possible to reduce pain, in-hospital time, respiratory and thromboembolic complications, convalescence and incisional hernia.

[The BIB intragastric balloon]. / Il palloncino intragastrico BIB.

INTRODUCTION: Since 1998, we adopted in our clinical practice for obesity treatment the new intragastric balloon (BioEnterics Intragastric Balloon, BIB), it has the characteristics of an "ideal gastric balloon" (Workshop Tarpon Springs, 1987). MATERIALS AND METHODS: Since March 1998 we have placed by endoscopic approach 518 BIB in 480 patients affected by first, second and severe morbid obesity; 124 male and 356 female, mean age 41.6 years (18-72), mean weight Kg 116.9 (67-229), mean BMI 42 Kg/m2 (27.34-81.14). All our patients underwent to diet of 1000 Kcal/day and treatment with antisecretory drugs. RESULTS: The mean weight lost was Kg 14.69 and the mean reduction in BMI was 5.11 Kg/m2. Weight loss was greater in male severe obese (BMI > 40). Weight was accompanied by an improvement of the disease associated with obesity, in particular diabetes, hypertension and sleep apnoea. DISCUSSION AND CONCLUSION: The best indication for BIB were: morbidly obese patients (BMI > 40) and super-obese patients (BMI > 50) in preparation for bariatric operation; obese patients with BMI 35-40 with co-morbilities in preparation for bariatric surgery; obese patients with BMI < 30 only in a multidisciplinary approach patients with BMI 30-35 with a chronic disease otherwise unresolved.

Prevention of pouch dilatation after laparoscopic adjustable gastric banding.

BACKGROUND: The major long-term complication of laparoscopic adjustable gastric banding (LAGB) is dilatation of the gastric pouch, that is reported with a frequency ranging from 1 to 25%, and often requires removal of the band. In addition to the usual recommendations of bariatric surgery centers and dietetic advice to prevent this complication, over the last 4 years we introduced a technical modification of the procedure. METHODS: From Nov 1993 to Dec 2004, 684 morbidly obese patients underwent adjustable gastric banding, 83 patients by open surgery and 601 patients by laparoscopy. The first 323 patients (group A) were operated by the perigastric approach, and 57 patients (group B) were operated by the pars flaccida approach. Since Dec 2000, 304 patients (group C) were operated with a modified pars flaccida technique, which consisted in suturing the gastric lesser curvature below the band with one or two stitches to the right phrenic crus to secure the band in place. RESULTS: In group A, the most important late complication was irreversible dilatation of the gastric pouch, which occurred in 35 patients (10.8%), and required removal of the band in 30 cases and replacement in 5. In group B, there were 3 pouch dilatations (5.2%). In group C, only 4 dilatations occurred (1.31%), which required 3 band removals and 1 band replacement. CONCLUSION: Dilatation of the gastric pouch appears to be dramatically reduced by our minor technical modification of band placement.

Adjustable gastric banding for morbid obesity. Our experience.

BACKGROUND: The adjustable gastric banding is considered the most common procedure in Europe for the treatment of morbid obesity. We report our experience with this procedure, that was introduced in our Departments of Surgery since 1993. METHODS: From December 1993 to December 2004, 684 morbid obese patients (139 males and 545 females) underwent adjustable gastric banding (AGB) in our departments of Surgery. The first 323 patients were operated with perigastric procedure, the following 361 patients with pars flaccida technique. 601 patients were operated with laparoscopic approach, 83 with open approach. The average follow-up is 5 years. RESULTS: Mean BMI decreased from 42.2 to 34 Kg/m2 five years after the operation, with an EWL of 54 %. The main early complications were: intraoperative gastric perforation (5 patients, 1 of which repaired in laparoscopy); hemorrhage from short gastric vessels (3 patient, repaired in laparotomy). The major late complications were: intragastric band migration (7 patients); irreversible dilatation of the gastric pouch (42 patients, treated surgically with band removal or repositioning). CONCLUSION: In our experience laparoscopic adjustable gastric banding is a safe and effective procedure, suitable to most patients, and should be considered as the first choice in the surgical treatment of morbid obesity.