Plasma amine oxidase: a postulated cardiovascular risk factor in nondiabetic obese patients.

Increased activity of semicarbazide-sensitive plasma amine oxidase (SSAO), an enzyme converting various amines, has been implicated in the generation of endothelial damage through formation of cytotoxic reaction products. We investigated if SSAO activity is elevated in morbidly obese patients, which might contribute to the increased cardiovascular risk associated with obesity. SSAO activity was determined in 74 nondiabetic, obese patients (median body mass index [BMI]: 42.9 kg/m(2)) and in 32 healthy, non-obese controls (median BMI: 23.3 kg/m(2)) using a radiometric assay based on the conversion of [(14)C]benzylamine. SSAO and parameters of glucose and lipid metabolism were compared for subgroups of obese patients with normal (n = 49) and impaired (n = 25) glucose tolerance using nonparametric statistical tests. Median SSAO activity was 434 microU/mL in obese patients, which was significantly higher than in healthy, non-obese controls (median SSAO activity: 361 microU/mL). Median SSAO activity in patients with normal and impaired glucose tolerance was 423 and 464 microU/mL, respectively. SSAO activity was not correlated with any other clinical or laboratory parameters characteristic of the metabolic alterations associated with obesity. Elevated SSAO activity is found in nondiabetic, morbidly obese patients and might be an interesting independent risk factor for obesity-related cardiovascular morbidity. Long-term follow-up of SSAO and its possible role in pathogenic events is warranted since intervention with specific SSAO inhibitors is available.

Adjustable gastric banding in a patient with sarcoidosis.

The use of silicone in patients with immune-compromising diseases is controversial because of fears that there may be inflammatory reactions against the material. We report the case of a patient who suffered from cutaneous sarcoidosis with bihilar lymphadenopathy and obesity (110 kg; BMI, 38 kg/m2) that was exaggerated by cortisone therapy. The patient underwent adjustable gastric banding because of aggravating comorbid hypertension and hyperlipidemia. Six months postoperatively, she had achieved an excess weight loss of 33%. During this period, she had a relapse of scar sarcoidosis of the right elbow and bilateral hilar lyphadenopathy. Although she was treated with a double dose of cortisone (8 mg daily), the scars from the laparoscopy as well as those in the gastric region adjacent to the band remained unaffected. We therefore believe that preexisting immune-compromising diseases are not an absolute contraindication against gastric banding, particularly since our patient experienced a notable improvement in her quality of life.

Improved scintigraphic assessment of occult leakages in adjustable gastric bands using 99mTc-labelled human albumin colloid.

BACKGROUND: Adjustable gastric banding has become the preferred procedure in Europe for the treatment of morbid obesity. A complication of this treatment is the presence of leakage in the system. The knowledge of the localization of the leak is essential for planning the reoperation procedure. PATIENTS AND METHODS: In a series of 325 adjustable gastric bandings, we observed 10 band leakages. In 3 cases, fluoroscopy failed to detect fluid extravasation. We present a sensitive and simple scintigraphic method for the detection of gastric band leakage in these patients using 37 MBq of a 99mTc-human albumin colloid suspension. Imaging was started immediately after the dose application. During the first minute, images were acquired dynamically with 1 frame every 2 seconds. Afterwards, a static image was obtained every 10 minutes, up to 60 minutes post-injection. Then the system was emptied completely to detect tracer extravasation and consecutive reabsorption during 60 minutes. The study was analyzed by using the regions of interest (ROI) technique drawn on the following points: injection reservoir, tube, anterior band, posterior band, and an adjacent region which was taken as background. RESULTS: During the first hour, ROI analysis showed a clear diminution in the number of counts contained in the defect parts of the band, whereas it remained constant in the other locations. After system emptying, detection of tracer extravasation further strengthened the diagnosis of band leakage in all patients. CONCLUSION: This new approach using the 99mTc-human albumin colloid suspension with ROI analysis is an effective and simple method to detect occult leakages in adjustable gastric bands which escaped detection by fluoroscopy. In contrast to previously described scintigraphic methods, this investigation is able to demonstrate the exact site of leakage.

Pregnancies after adjustable gastric banding.

BACKGROUND: We evaluated outcome of pregnancies of morbidly obese women who are within the first 2 years after laparoscopic adjustable gastric banding. METHODS: 215 morbidly obese women of reproductive potential (age 18-45 years), who had agreed to remain on reliable contraceptives for 2 years after surgery, were retrospectively analyzed following bariatric surgery. RESULTS: 7 unexpected pregnancies were observed. 5 pregnancies were full-term (3 vaginal and 2 cesarean deliveries). The birth weights ranged from 2110 g to 3860 g. 2 women had first trimester miscarriages. All gastric bands were completely decompressed due to nausea and vomiting, resulting in further weight gain. 2 serious band complications were observed (1 intragastric band migration and 1 balloon defect), which required re-operation. CONCLUSIONS: Pregnancy in morbidly obese women soon after adjustable gastric banding may occur unexpectedly during a period of weight loss. Prophylactic fluid removal from the band eliminates the efficacy of the obesity treatment. Moreover, this cohort shows an increased incidence of spontaneous abortions and band-related complications.

A study of pain after laparoscopic gastric banding.

BACKGROUND: The introduction of the laparoscopic approach to bariatric surgery has brought similar advantages as those seen in general surgery. There have been no trials assessing postoperative pain after laparoscopic adjustable silicone gastric banding (LASGB). We compared prospectively postoperative pain and outcome in LASGB and laparoscopic cholecystectomy (LC), to determine if morbidly obese patients can expect the same benefits from a laparoscopic approach in gastric banding as those which are known for LC in non-obese and obese patients. METHODS: In a prospectively collected database of 80 patients undergoing LASGB, information including a survey assessing the postoperative pain, the amount of analgetic drugs used, operative reports, laboratory data, and follow-up data was collected. This was compared to an equal number of patients undergoing LC. Postoperatively, all patients received standardized pain medication of 150 mg tramadol per day. Pain was assessed twice on postoperative days 1-3 using a patient questionnaire. RESULTS: Patient characteristics and duration of hospital stay were similar in the two groups. Although there was no significant difference in type and intensity of pain experienced by the patients in either group, the gastric banding patients reported less postoperative pain overall than those in the LC group. CONCLUSION: The analyzed data show that LASGB offers the same advantages as other laparoscopic operations, in that it induces less pain and enables the patient to return quickly to normal activity and work. The advantage over the compared LC group may be due to higher patient motivation, but was not statistically significant.

Effects of norepinephrine and phenylephrine on intestinal oxygen supply and mucosal tissue oxygen tension.

OBJECTIVES: To investigate effects of intravenous norepinephrine (NE) and phenylephrine (PE) on intestinal oxygen supply in an autoperfused, innervated jejunal segment. DESIGN AND SETTING: Prospective, randomized animal study in an animal research laboratory. MATERIALS AND METHODS: In 24 anesthetized and normoventilated pigs a segment of the jejunal mucosa was exposed by midline laparotomy and antimesenteric incision. Mucosal oxygen tension (PO2muc; Clark-type surface oxygen electrodes), microvascular hemoglobin oxygen saturation (HbO2, tissue reflectance spectrophotometry), and microvascular blood flow (perfusion units, PU; laser Doppler velocimetry), systemic hemodynamics, mesenteric-venous acid base and blood gas variables, and systemic acid base and blood gas variables were recorded after a resting period and at 20-min intervals during infusion of NE (0.01, 0.05, 0.1, 0.5, 1, 2 micrograms x kg-1 x min-1; n = 8) or PE (0.1, 0.5, 1, 2, 5, 10 micrograms x kg-1 x min-1; n = 8) and in controls (n = 8) without treatment. RESULTS: NE infusion led to significant tachycardia, an increase in cardiac output, and systemic oxygen delivery and consumption while PE progressively increased mean arterial pressure with only small effects on systemic blood flow. NE or PE infusion did not affect mesenteric venous oxygen tension (baseline: PE 53 +/- 5, NE, 52 +/- 4.2 mmHg), mesenteric oxygen extraction ratio (baseline: PE 0.29 +/- 0.08, NE 0.3 +/- 0.06), jejunal microvascular blood flow (baseline: PE 254 +/- 127, NE 282 +/- 72 PU), PO2muc (baseline: PE 31 +/- 9.1, NE 33 +/- 11 mmHg), and HbO2 (baseline: PE 52 +/- 9.6%, NE 58 +/- 11.6%). CONCLUSION: Despite major differences in systemic hemodynamics jejunal tissue oxygen supply is not affected by progressively increasing intravenous infusion of norepinephrine and phenylephrine.

Effects of epinephrine on intestinal oxygen supply and mucosal tissue oxygen tension in pigs.

OBJECTIVE: To study the effects of increasing dosages of epinephrine given intravenously on intestinal oxygen supply and, in particular, mucosal tissue oxygen tension in an autoperfused, innervated jejunal segment. DESIGN: Prospective, randomized experimental study. SETTING: Animal research laboratory. SUBJECTS: Domestic pigs. INTERVENTIONS: Sixteen pigs were anesthetized, paralyzed, and normoventilated. A small segment of the jejunal mucosa was exposed by midline laparotomy and antimesenteric incision. Mucosal oxygen tension was measured by using Clark-type surface oxygen electrodes. Microvascular hemoglobin oxygen saturation and microvascular blood flow (perfusion units) were determined by tissue reflectance spectrophotometry and laser-Doppler velocimetry. Systemic hemodynamics, mesenteric-venous acid-base and blood gas variables, and systemic acid-base and blood gas variables were recorded. Measurements were performed after a resting period and at 20-min intervals during infusion of increasing dosages of epinephrine (n = 8; 0.01, 0.05, 0.1, 0.5, 1, and 2 microg x kg(-1) x min(-1)) or without treatment (n = 8). In addition, arterial and mesenteric-venous lactate concentrations were measured at baseline and at 60 and 120 mins. MEASUREMENTS AND MAIN RESULTS: Epinephrine infusion led to significant tachycardia; an increase in cardiac output, systemic oxygen delivery, and oxygen consumption; and development of lactic acidosis. Epinephrine significantly increased jejunal microvascular blood flow (baseline, 267 +/- 39 perfusion units; maximum value, 443 +/- 35 perfusion units) and mucosal oxygen tension (baseline, 36 +/- 2.0 torr [4.79 +/- 0.27 kPa]; maximum value, 48 +/- 2.8 torr [6.39 +/- 0.37 kPa]) and increased hemoglobin oxygen saturation above baseline. Epinephrine increased mesenteric venous lactate concentration (baseline, 2.9 +/- 0.6 mmol x L(-1); maximum value, 5.5 +/- 0.2 mmol x L(-1)) without development of an arterial-mesenteric venous lactate concentration gradient. CONCLUSIONS: Epinephrine increased jejunal microvascular blood flow and mucosal tissue oxygen supply at moderate to high dosages. Lactic acidosis that develops during infusion of increasing dosages of epinephrine is not related to development of gastrointestinal hypoxia.

Results and complications after adjustable gastric banding in a series of 250 patients.

BACKGROUND: Morbid obesity contributes to many health risks including physical, emotional, and social problems. The increasing prevalence of obesity is a major public health concern since obesity is associated with several chronic diseases. Morbid obesity is the biggest independent risk factor for early mortality. Various options for the surgical treatment of morbid obesity have been developed with varying results. METHODS: Between January 1996 and December 1999, we operated on a series of 250 patients (200 women and 50 men) at the General Surgical Department of the University Hospital in Innsbruck. The parameters that were evaluated included age, preoperative and postoperative body mass index (BMI), type of surgery, and intraoperative and postoperative complications. RESULTS: The mean follow-up period was 12 months (range 3 to 18). The average preoperative weight was 135.5 kg (BMI 46.69 kg/m(2)). The average total weight-loss was 5.5 kg per month, reaching an average total of 35 kg after one year. The excess weight loss (EWL) after 12 months was 72%. Complications requiring reoperation occurred in 8.8%. CONCLUSIONS: In the first year after laparoscopic adjustable gastric banding, weight reduction of the study population was excellent. Additionally, the complication rate was reasonable with no mortalities.

Effects of adjustable gastric banding on altered gut neuropeptide levels in morbidly obese patients.

BACKGROUND: Patients with gastroesophageal reflux disease (GERD) have alterations of gut neuropeptides, such as neurotensin (N) and motilin (M), which are resolved following antireflux surgery. Obesity is associated with GERD. Since the adjustable gastric band prevents gastroesophageal reflux in morbidly obese patients, this study was performed to investigate plasma levels of N and M before and after adjustable gastric banding (AGB). METHODS: 47 morbidly obese patients were operated laparoscopically using the Swedish AGB. Pre- and postoperatively basal plasma levels of N and M were investigated. Symptoms such as heartburn, regurgitation and dysphagia were documented, and esophageal manometry as well as 24-hour pH-monitoring were performed pre- and postoperatively. 11 non-obese, asymptomatic, age-matched volunteers served as controls. RESULTS: After a median postoperative follow-up period of 268 days, a significant weight reduction was observed. Preoperatively, 14 patients suffered from reflux symptoms. An insufficient lower esophageal sphincter (LES) was found in 8 patients, and 2 patients had impaired esophageal body motility. Pathologic pH-testing was found in 6 patients. Postoperatively, reflux symptoms were present in 4 patients; LES findings and pH-testing were normalized in all patients. However, there was significant impairment of esophageal peristalsis. Preoperatively, levels of N were significantly decreased and levels of M increased compared with control subjects. Postoperatively, there was a significant increase of N and levels of M were normalized. Alterations in gut neuropeptides did not correlate with reflux symptoms, impaired gastroesophageal motility, age, gender or BMI. CONCLUSION: Morbid obesity alters gut neuropeptides, which are resolved by AGB. This may be caused by reduction of hypercaloric nutrition postoperatively rather than by improvement of gastroesophageal reflux.

Organ transplantation and obesity: evaluation, risks and benefits of therapeutic strategies.

Obesity is a prevalent health problem that has discernible impact on all fields of surgery. However, little attention is paid in the literature to the underlying relation of surgical, immunological and metabolic links between transplantation and morbid obesity. Pre-operative obesity has been reported to worsen the outcome of organ transplantation. Impairment of graft function as well as decreased patient and graft survival can contribute to this effect. Post-transplant weight gain is common and may be attributed to an imbalance of the adipostatic and appetite stimulating hormones. Reduction of obesity before transplantation has to cope with limited time, increased risk of therapeutic side-effects in patients with end-stage organ failure, and psychosocial stress. Overweight reduction following organ transplantation interferes with diverse effects associated with immunosuppressive therapy. A case of adjustable gastric banding following renal transplantation is presented.

Injection port complications after gastric banding: incidence, management and prevention.

BACKGROUND: Laparoscopic adjustable gastric banding is advocated as a minimal invasive procedure with a low risk profile and high efficacy in the treatment of morbid obesity. Nevertheless, injection port complications are occasionally reported. The aim of this study was to assess port disconnections and port dislodgement with respect to two different implantation techniques. METHODS: Between January 1996 and October 1999 230 patients underwent laparoscopic gastric banding with the Swedish Adjustable Gastric Band (SAGB). In group 1 (118 patients), the injection port was implanted onto the sterno-xiphoid union. In group 2 (112 patients), an additional incision was made to suture the port onto the fascia of the lower third of the sternum. RESULTS: There is a significant reduction in port disconnection between group 1 (9.3 %) and group 2 (0 %). Port dislodgment was observed in one patient in each group. Reoperation was performed under local anesthesia in 11 patients, and general anesthesia was used for laparoscopic tube salvage in two patients. After reconnection, two patients experienced port infection. CONCLUSION: Correct implantation technique of the injection port of the SAGB onto the fascia of the lower third of the sternum reduces the risk for port complications. Technical notes are discussed.

Gastroscopic band removal after intragastric migration of adjustable gastric band: a new minimal invasive technique.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is the most used procedure for bariatric surgery in Europe. Although a low complication rate is reported, band migration within the first 2 years after LAGB is still observed in nearly 5% of cases, requiring operative band removal. To avoid increased risk of complications due to laparotomy, we propose a minimally invasive technique for this purpose. METHODS: We performed this operation in five patients who suffered from band migration after LAGB (1.9% in our series of 211 patients, one patient was operated elsewhere). The described method consists of gastroscopic band and tube removal, combined with removal of the port under local anesthesia. RESULTS: The described procedure was developed in the endoscopy unit without additional equipment. The mean operating-time ranged from 65 to 180 minutes (mean 135 minutes). No perioperative complication were observed. In-patient treatment was necessary for 4 days. CONCLUSIONS: A novel technique for minimally invasive band removal after adjustable gastric band migration is described, offering the patient a low-risk procedure and a better chance for further laparoscopic approaches.

Aberrant left hepatic artery in laparoscopic gastric banding.

BACKGROUND: The aberrant left hepatic artery (ALHA) is an anatomic variation which may be an obstacle in the laparoscopic gastric banding operation. Based on our experience, our mission was to answer the questions: How frequently is an ALHA encountered? Is division necessary? Are there any additional complications in cases where the ALHA is preserved? METHODS: In a prospectively collected database of 270 patients undergoing laparoscopic gastric banding in our unit, information including presence of an ALHA, clinical data, diagnostic work-up, operative reports, laboratory data, and follow-up data were collected. RESULTS: In 48 patients (17.7%) (39 women, 9 men, mean age 39.2 years) an ALHA was observed. Hiatal dissection was not impaired in any of these patients, and none required division of the ALHA. In all but two cases, the band was placed above the ALHA, offering additional stability to the band positioning. In 2 patients (4.1%), the artery was injured during dissection and was divided due to ongoing bleeding. Twenty-two (45.8%) of the ALHAs were of intermediate or large size. Neither pouch dilatation nor band slippage occurred in the above-mentioned group. The two patients with divided hepatic arteries had no postoperative symptoms related to impaired liver function. CONCLUSIONS: ALHA is not an uncommon finding during laparoscopic gastric banding and may be found in approximately 18% of patients. Division can nearly always be avoided and may be required only in selected cases due to bleeding. Patients do not experience clinical complications after division, although liver enzymes may be temporarily elevated, and no monitoring is necessary.

Treatment of morbid obesity with laparoscopic adjustable gastric banding affects esophageal motility.

BACKGROUND: Laparoscopic adjustable gastric banding has become the prefered method for the surgical treatment of morbid obesity in Europe. It is not known whether this procedure may induce gastroesophageal reflux and whether it may impair esophageal peristalsis. METHODS: Laparoscopic adjustable gastric banding (Swedish band) was performed in 43 patients (median body mass index [BMI] 42.5 kg/m(2)). Preoperatively and 6 months postoperatively all patients were assessed for reflux symptoms. In addition all patients underwent preoperative and postoperative endoscopy, esophageal barium studies and manometry, and 24-hour esophageal pH-monitoring. RESULTS: The median BMI dropped significantly to 33.1 kg/m(2) (P <0.05). Preoperatively 12 patients complained of reflux symptoms. Mild esophagitis was detected in 10 patients. Postoperatively only 1 patient complained of heartburn and mild esophagitis was diagnosed in another patient. None of the patients had dysphagia. Preoperatively a defective LES and pathologic pH-testing were found in 9 and 15 patients, respectively. These parameters were normal in all of the patients postoperatively. Postoperatively there was significant impairment of LES relaxation and deterioration of esophageal peristalsis with dilatation of the esophagus in some of the patients. CONCLUSION: Laparoscopic adjustable gastric banding provides a sufficient antireflux barrier and therefore prevents pathologic gastroesophageal reflux. However, it impairs relaxation of the LES, leading to weak esophageal peristalsis.