Comparison of 3D endoanal ultrasound and external phased array magnetic resonance imaging in the diagnosis of obstetric anal sphincter injuries.

OBJECTIVES: The gold standard of postpartum anal sphincter imaging has been the 3D endoanal ultrasound (EAUS). Development of magnetic resonance imaging (MRI) has allowed anal sphincter evaluation without the use of endoanal coils. The aim of this study is to compare these two modalities in diagnosing residual sphincter lesions post obstetric anal sphincter injury (OASI). METHODS: Forty women were followed up after primary repair of OASI with both 3D EAUS and external phased array MRI. Details of the anal sphincter injury and sphincter musculature were gathered and analysed. RESULTS: There was a moderate interrater reliability (κ = 0.510) between the two imaging modalities in detecting sphincter lesions, with more lesions detected by MRI. There was a moderate intraclass correlation (ICC) between the circumference of the tear (κ = 0.506) and a fair ICC between the external anal sphincter thickness measurements at locations 3 and 9 on the proctologic clock face (κ = 0.320) and (κ = 0.336). CONCLUSIONS: The results of our study indicate that the use of external phased array MRI is feasible for detecting obstetric anal sphincter lesions postpartum. This allows for imaging of the sphincter defects in centres where EAUS imaging is not available. KEY POINTS: • A two centre prospective study that showed external phased array MRI to be a valid imaging modality for diagnosing obstetric anal sphincter injuries.

Impact of sphincter lesions and delayed sphincter repair on sacral neuromodulation treatment outcomes for faecal incontinence: results from a Finnish national cohort study.

PURPOSE: The aim of this multicentre study was to analyse the effects of patent sphincter lesions and previous sphincter repair on the results of sacral neuromodulation (SNM) treatment on patients with faecal incontinence (FI). METHODS: Patients examined by endoanal ultrasound (EAUS) with FI as the indication for SNM treatment were included in the study. Data was collected from all the centres providing SNM treatment in Finland and analysed for differences in treatment outcomes. RESULTS: A total of 237 patients treated for incontinence with SNM had been examined by EAUS. Of these patients, 33 had a history of previous delayed sphincter repair. A patent sphincter lesion was detected by EAUS in 128 patients. The EAUS finding did not influence the SNM test phase outcome (p = 0.129) or the final treatment outcome (p = 0.233). Patient's history of prior sphincter repair did not have a significant effect on the SNM test (p = 0.425) or final treatment outcome (p = 0.442). CONCLUSIONS: Results of our study indicate that a sphincter lesion or previous sphincter repair has no significant effect on the outcome of SNM treatment. Our data suggests that delayed sphincter repair prior to SNM treatment initiation for FI is not necessary.

Effect of Laparoscopic Sleeve Gastrectomy vs Laparoscopic Roux-en-Y Gastric Bypass on Weight Loss at 5 Years Among Patients With Morbid Obesity: The SLEEVEPASS Randomized Clinical Trial.

Importance: Laparoscopic sleeve gastrectomy for treatment of morbid obesity has increased substantially despite the lack of long-term results compared with laparoscopic Roux-en-Y gastric bypass. Objective: To determine whether laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass are equivalent for weight loss at 5 years in patients with morbid obesity. Design, Setting, and Participants: The Sleeve vs Bypass (SLEEVEPASS) multicenter, multisurgeon, open-label, randomized clinical equivalence trial was conducted from March 2008 until June 2010 in Finland. The trial enrolled 240 morbidly obese patients aged 18 to 60 years, who were randomly assigned to sleeve gastrectomy or gastric bypass with a 5-year follow-up period (last follow-up, October 14, 2015). Interventions: Laparoscopic sleeve gastrectomy (n = 121) or laparoscopic Roux-en-Y gastric bypass (n = 119). Main Outcomes and Measures: The primary end point was weight loss evaluated by percentage excess weight loss. Prespecified equivalence margins for the clinical significance of weight loss differences between gastric bypass and sleeve gastrectomy were -9% to +9% excess weight loss. Secondary end points included resolution of comorbidities, improvement of quality of life (QOL), all adverse events (overall morbidity), and mortality. Results: Among 240 patients randomized (mean age, 48 [SD, 9] years; mean baseline body mass index, 45.9, [SD, 6.0]; 69.6% women), 80.4% completed the 5-year follow-up. At baseline, 42.1% had type 2 diabetes, 34.6% dyslipidemia, and 70.8% hypertension. The estimated mean percentage excess weight loss at 5 years was 49% (95% CI, 45%-52%) after sleeve gastrectomy and 57% (95% CI, 53%-61%) after gastric bypass (difference, 8.2 percentage units [95% CI, 3.2%-13.2%], higher in the gastric bypass group) and did not meet criteria for equivalence. Complete or partial remission of type 2 diabetes was seen in 37% (n = 15/41) after sleeve gastrectomy and in 45% (n = 18/40) after gastric bypass (P > .99). Medication for dyslipidemia was discontinued in 47% (n = 14/30) after sleeve gastrectomy and 60% (n = 24/40) after gastric bypass (P = .15) and for hypertension in 29% (n = 20/68) and 51% (n = 37/73) (P = .02), respectively. There was no statistically significant difference in QOL between groups (P = .85) and no treatment-related mortality. At 5 years the overall morbidity rate was 19% (n = 23) for sleeve gastrectomy and 26% (n = 31) for gastric bypass (P = .19). Conclusions and Relevance: Among patients with morbid obesity, use of laparoscopic sleeve gastrectomy compared with use of laparoscopic Roux-en-Y gastric bypass did not meet criteria for equivalence in terms of percentage excess weight loss at 5 years. Although gastric bypass compared with sleeve gastrectomy was associated with greater percentage excess weight loss at 5 years, the difference was not statistically significant, based on the prespecified equivalence margins. Trial Registration: clinicaltrials.gov Identifier: NCT00793143.

Mortality Following Bariatric Surgery Compared to Other Common Operations in Finland During a 5-Year Period (2009-2013). A Nationwide Registry Study.

PURPOSE: A concern regarding the safety of bariatric surgery may explain the fact that only a minor fraction of morbidly obese patients has access to it. This is a population-based, nationwide study reporting 30-day, 90-day, and 1-year mortality rates following bariatric surgery in comparison with mortality rates after other common operations in Finland. MATERIALS AND METHODS: Patients undergoing surgery between January 2009 and December 2013 were included. Data on surgical procedures were obtained from the national hospital discharge registry, and cause of death was obtained from Statistics Finland. RESULTS: Inclusion criteria were met by 156,536 patients. Of these, 3918 underwent surgery for morbid obesity. Three patients (0.08%) died within 30 days following bariatric surgery. The 30-day mortality rate was lower only following prostatectomy. Compared with bariatric surgery, the hazard ratios (HR) for 1-year postoperative mortality were significantly higher for elective cholecystectomy (HR 2.38, 95% CI 1.39-4.08, p = 0.002), hysterectomy (HR 2.87, 95% CI 1.68-4.92, p < 0.001), knee arthroplasty (HR 2.23, 95% CI 1.31-3.81, p = 0.003), hip arthroplasty (HR 11.7, 95% CI 6.90-19.8, p < 0.001), colorectal resections (HR 27.5, 95% CI 16.2-46, p < 0.001), gastric resection (HR 53.0, 95% CI 30.2-93.2, p < 0.001), gastrectomy (HR 74.7, 95% CI 43.0-130, p < 0.001), and coronary artery bypass grafting (HR 30.7, 95% CI 17.4-54.3, p < 0.001). CONCLUSION: Mortality rates following bariatric surgery are low and similar or lower than mortality rates following all other common elective surgeries.

[Fast track bariatric surgery]. / Lihavuuskirurgia nopean toipumisen ohjelmalla.

BACKGROUND: Relatively little is known about the use of fast track protocols in bariatric surgery. MATERIAL AND METHODS: We carried out an observational study of 422 consecutive patients who underwent bariatric surgery by a fast track protocol. RESULTS: Mean length of stay was 1.3 days, median 1 day. Of all patients, 83% were discharged on the first postoperative day. Three patients (0.7%) had life-threatening complications. The readmission rate was 4.7%, and 3.3% of the patients had to be reoperated. The body weight dropped 31% in a year. CONCLUSIONS: Early discharge does not seem to increase postoperative morbidity or readmissions.

Factors predicting a failed primary repair of obstetric anal sphincter injury.

INTRODUCTION: The success of the primary repair of obstetric anal sphincter injury (OASI) is paramount in maintaining adequate fecal continence after childbirth. The factors determining the success or failure of primary repair are unclear. The aim of this study is to investigate modifiable factors determining the success or failure of the primary sphincter repair after OASI. MATERIAL AND METHODS: Sixty women with OASI were investigated by endoanal ultrasound or magnetic resonance imaging, and with the Wexner incontinence questionnaire. Based on the findings, the women were divided in two groups; successful primary repair group (n = 41) and failed primary repair group (n = 19). RESULTS: The primary repair failed in 31.7% of the tears. These included more tears repaired by less experienced personnel (p < 0.001) and more repairs performed during on-call hours (p = 0.039) than in the successful primary repair group. Significantly more pain medication was used in the failed group (p = 0.003), and the use of antibiotics and laxatives after the repair was more common in the successful group (p < 0.001). Sphincter injuries were repaired using the overlapping suture technique in 95.1% of the repairs in the successful group compared with 47.4% in the failed group (p = 0.03). The mean (SD) Wexner score was significantly higher in the failed group [5.92 (4.1) vs. 1.88 (4.2), p < 0.001], in agreement with the findings on endoanal ultrasound. CONCLUSIONS: Postpartum perineal tears should be evaluated by personnel familiar with the diagnosis and repair of OASI. Delaying the primary repair until next morning is recommended if experienced personnel are unavailable during on-call hours.

Outcome of Laparoscopic Gastric Bypass (LRYGB) with a Program for Enhanced Recovery After Surgery (ERAS).

BACKGROUND: Enhanced recovery after surgery (ERAS) programs are well established for patients undergoing colorectal surgery. Relatively little is known about ERAS following bariatric surgery in general or following laparoscopic Roux-en-Y gastric bypass (LRYGB) in particular. PATIENTS AND METHODS: This is a prospective, observational study of 388 consecutive patients that underwent LRYGB with ERAS in a general hospital. The ERAS protocol included standardizations of pre-, intra-, and postoperative modalities in order to reduce the stress response of the patients. Primary outcome measures were length of stay (LOS), postoperative morbidity, readmissions, and reoperations. RESULTS: Mean (SD) baseline body mass index (BMI) and age was 46.4 (6.7) kg/m(2) and 45.1 (11.2) years, respectively. Fifty-four percent of the patients were on medication for hypertension (HT) and 38 % for type 2 diabetes mellitus (DM2). Mean (SD) and median (range) surgical time was 73.8 (16.9) and 65 (40-143) min, respectively. Mean LOS was 1.3 days (1.1), median 1 day (1-14). Of all patients, 322 (83 %) were discharged on the first postoperative day (POD). Overall morbidity was 9.8 %. Three patients (0.8 %) had life-threatening complications. The readmission rate was 4.9 %, and 3.4 % of the patients had to be reoperated. With a follow-up rate of 83 % at 1 year, total weight loss (TWL) was 31 % and excess BMI loss (EBMIL) 70 %. Total remission of DM2 and HT was achieved in 70 and 42 % of the patients, respectively. CONCLUSION: Enhanced recovery following LRYGB with ERAS programs is possible and safe even in a low volume, general hospital. Early discharge does not increase postoperative morbidity or readmissions.

Can Laparoscopic Cholecystectomy Prevent Recurrent Idiopathic Acute Pancreatitis?: A Prospective Randomized Multicenter Trial.

OBJECTIVE: The aim of the present trial was to ascertain whether laparoscopic cholecystectomy (LCC) can prevent recurrent attacks of idiopathic acute pancreatitis (IAP). SUMMARY: Up to 50% to 75% of IAP may be due to microlithiasis, which is undetectable by conventional imaging methods. METHODS: This randomized, prospective trial included 85 patients (39 in the LCC and 46 in the control group) in 8 hospitals in Finland. We included adult patients (over 18 years) with their first attack of IAP. The diagnosis of IAP was based on the exclusion of common etiological reasons for acute pancreatitis (AP), whereafter the patients were randomized into conservative watchful waiting (controls) or LCC group. The primary end point was the number of patients with recurrent AP during the follow-up. All recurrent attacks of AP after an initial IAP episode were registered. RESULTS: During a median follow-up of 36 (5-58) months, the recurrence of IAP was significantly higher in the control group than in LCC group (14/46 vs. 4/39, P = 0.016), as was also the number of recurrences (23/46 vs. 8/39, P = 0.003). In the subgroup of patients with at least 24 months' follow-up, the recurrence was still higher among controls (14/37 vs. 4/35, P = 0.008). In patients with normal liver function, recurrence was also significantly higher in the control than in the LCC group (13/46 vs. 4/39, P = 0.026). During surgery, 23/39 (59%) of the gallbladders were found to contain biliary stones or sludge. CONCLUSIONS: LCC can effectively prevent the recurrence of IAP when all other possible etiologies of pancreatitis are carefully excluded. A total of 5 patients needed to be treated (NNT-value) to prevent 1 IAP.

Bariatric surgery in elderly patients: a systematic review.

Controversy exists regarding the effectiveness and safety of bariatric/metabolic surgery in elderly patients. We performed a systematic review on this issue in patients aged 60 years or older. MEDLINE, Cochrane Library, Embase, Scopus, and Google Scholar were searched until August 2015 for studies on outcomes of bariatric surgery in elderly patients. The results were expressed as pooled proportions (%) with 95% confidence intervals. Heterogeneity across the studies was evaluated by the I (2) test, and a random-effects model was used. Twenty-six articles encompassing 8,149 patients were pertinent with this issue and included data on bariatric surgery outcomes in elderly population. Fourteen patients died during the 30-day postoperative period, with a pooled mortality of 0.01%. Pooled overall complication rate was 14.7%. At 1-year follow-up, pooled mean excess weight loss was 53.77%, pooled diabetes resolution was 54.5%, and pooled hypertension resolution was 42.5%, while pooled lipid disorder resolution was 41.2%. Outcomes and complication rates of bariatric surgery in patients older than 60 years are comparable to those in a younger population, independent of the type of procedure performed. Patients should not be denied bariatric surgery because of their age alone.

Prospective, Randomized Study on the Use of a Prosthetic Mesh for Prevention of Parastomal Hernia of Permanent Colostomy.

BACKGROUND: Prophylactic placement of a mesh has been suggested to prevent parastomal hernia, but evidence to support this approach is scarce. OBJECTIVE: The aim of this study was to evaluate whether laparoscopic placement of a prophylactic, dual-component, intraperitoneal onlay mesh around a colostomy is safe and prevents parastomal hernia formation after laparoscopic abdominoperineal resection. DESIGN: This is a prospective, multicenter, randomized controlled clinical trial. SETTINGS: This study was conducted at 2 university and 3 central Finnish hospitals. PATIENTS: From 2010 to 2013, 83 patients undergoing laparoscopic abdominoperineal resection for rectal cancer were recruited. After withdrawals and exclusions, the outcome of 70 patients, 35 patients in each study group, could be examined. INTERVENTIONS: In the intervention group, an end colostomy was created with placement of a intraperitoneal, dual-component onlay mesh and compared with a group with a traditional stoma. MAIN OUTCOME MEASURES: The main outcome measures were the incidence of clinically and radiologically detected parastomal hernias and their extent 12 months after surgery. Stoma-related morbidity and the need for surgical repair of parastomal hernia were secondary outcome measures. RESULTS: Parastomal hernia was observed by clinical inspection in 5 intervention patients (14.3%) and in 12 control patients (32.3%; p = 0.049). Surgical repair of parastomal hernia was performed in 1 control patient (3.2%) and in none of the patients in the intervention group. CT detected parastomal hernia in 18 intervention patients (51.4%) and in 17 control patients (53.1%; p = 1.00). The extent of hernias was similar according to European Hernia Society classification (p = 0.41). Colostomy-related morbidity (32.3% vs 14.3%; p = 0.140) did not differ between the study groups. LIMITATIONS: The study was limited by its small size and short follow-up time. CONCLUSIONS: Prophylactic laparoscopic placement of intraperitoneal onlay mesh does not significantly reduce the overall risk of radiologically detected parastomal hernia after laparoscopic abdominoperineal resection. However, prophylactic mesh repair was associated with significantly lower risk of clinically detected parastomal hernia.

Laparoscopic versus open adhesiolysis for small bowel obstruction - a multicenter, prospective, randomized, controlled trial.

BACKGROUND: Laparoscopic adhesiolysis is emerging as an alternative for open surgery in adhesive small bowel obstruction. Retrospective studies suggest that laparoscopic approach shortens hospital stay and reduces complications in these patients. However, no prospective, randomized, controlled trials comparing laparoscopy to open surgery have been published. METHODS/DESIGN: This is a multicenter, prospective, open label, randomized, controlled trial comparing laparoscopic adhesiolysis to open surgery in patients with computed-tomography diagnosed adhesive small bowel obstruction that is not resolving with conservative management. The primary study endpoint is the length of postoperative hospital stay in days.Sample size was estimated based on preliminary retrospective cohort, which suggested that 102 patients would provide 80% power to detect a difference of 2.5 days in the length of postoperative hospital stay with significance level of 0.05. Secondary endpoints include passage of stool, commencement of enteral nutrition, 30-day mortality, complications, postoperative pain, and the length of sick leave. Tertiary endpoints consist of the rate of ventral hernia and the recurrence of small bowel obstruction during long-term follow-up. Long-term follow-up by letter or telephone interview will take place at 1, 5, and 10 years. DISCUSSION: To the best of our knowledge, this trial is the first one aiming to provide level Ib evidence to assess the use of laparoscopy in the treatment of adhesive small bowel obstruction. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01867528. Date of registration May 26th 2013.

Laparoscopic Roux-en-Y gastric bypass is effective and safe in over 55-year-old patients: a comparative analysis.

BACKGROUND: Controversy exists regarding the effectiveness and safety of laparoscopic Roux-en-Y gastric bypass (LRYGB) in elderly patients. We evaluated our outcomes of LRYGB in patients aged ≥ 55 years. METHODS: A total of 549 consecutive patients underwent LRYGB as primary operation and 132 were ≥ 55 years old. Patients were divided in two groups: group <55 years comprised 417 patients, with mean age (± SD) of 41.15 ± 8.47 years; group ≥ 55 years comprised 132 patients, with mean age of 59.43 ± 3.81 years. Mean preoperative body mass index was 47.01 ± 7.47 and 46.21 ± 7.47 respectively, whereas mean excess weight loss percent (EW%) was 88.06 ± 30.28 and 84.86 ± 29.87 %. Early morbidity (30 days) and outcomes at 6, 12, and 24 months follow-up were evaluated. RESULTS: Significant difference was found in operative time (84.19 ± 29.05 vs. 90.89 ± 30.95 min, p = 0.03). One conversion to open procedure occurred in group <55 years, whereas three occurred in group ≥ 55 years (p = 0.04). Intraoperative complications occurred in 22 patients (5.27 %) in group <55 years versus 19 in group ≥ 55 years (14.39 %), which was statistically significant (p = 0.001). One case of death occurred in the younger group. Overall postoperative morbidity rate was 18.7 % in group <55 years and 25.76 % in group ≥ 55 years, with no significant difference (p = 0.08). Mean EWL% at 12 months in group <55 years was 65.95.05 ± 26.96 versus 62.61 ± 41.78 in group ≥ 55 years, whereas at 24 months it was 65.08 ± 29.68 versus 64.48 ± 18.44 with no significant difference between the groups (p = 0.51; p = 0.92). CONCLUSIONS: LRYGB for patients ≥ 55 years achieves outcomes and complications rates comparable to the younger population. Patients should not be denied bariatric surgery for the age alone.

Desire for body contouring surgery after bariatric surgery: do body mass index and weight loss matter?

BACKGROUND: There is disparity between the number of postbariatric surgery subjects who desire body contouring and those who receive it due to lack of resources or insurance criteria. OBJECTIVES: The authors evaluate the desire for body contouring after bariatric surgery and its relationship with demographic patient characteristics. METHODS: Three hundred sixty patients who had undergone bariatric surgery procedures >1 year previously completed a questionnaire designed by the surgical team to analyze each patient's desire for body contouring by area (face, upper arm, upper back, chin/neck, chest/breast, waist/abdomen, lower back, rear/buttock), scored from 0 to 3 (do not want, want somewhat, want, want a great deal). Data were compared with patient characteristics, postoperative body mass index (BMI), amount of weight loss, and BMI difference (ΔBMI). RESULTS: Most patients desired body contouring surgery, with high or very high desire for waist/abdomen (62.2%), upper arm (37.6%), chest/breast (28.3%), and rear/buttock (35.6%) contouring. Many patients (36.4%) cited "very high" expectations for how body contouring might change their appearance. Patients >50 years old and >3 years postsurgery had a significantly lower desire. Patients with a ΔBMI >10 and with a weight loss >20 kg showed a significantly stronger overall desire for body contouring compared with other groups. CONCLUSIONS: Most patients desire body contouring surgery after bariatric surgery, and our multivariate analysis showed a significant positive association between female sex, younger age, amount of weight loss, and ΔBMI with desire for body contouring.

The impact of preoperative weight loss before laparoscopic gastric bypass.

BACKGROUND: The impact of preoperative weight loss on outcomes following laparoscopic Roux-en-Y gastric bypass (LRYGB) is a controversial issue. We evaluated our outcomes of LRYGB in patients who lost different amount of weight prior to surgery. METHODS: Patients who underwent primary LRYGB were divided in three groups on the basis of preoperative weight loss percentage. Group A comprised 166 patients, who lost <5% of their weight preoperatively; group B comprised 239 patients who lost >5 to 10% and group C included 143 patients who lost >10%. Intra- and postoperative complications at 30 days, hospital stay, and outcomes were evaluated. RESULTS: Significant difference was found in operative (mean ± SD) time [104.43 ± 36.40 min in group A, 80.08 ± 23.07 min in group B, and 76.99 ± 23.23 min in group C; p < 0.001 in group A versus group B or group C; p = 0.210 in group B versus group C]. Difference in hospital stay was significant (3.33 ± 3.22 days in group A, 2.10 ± 2.77 in group B, and 1.87 ± 1.44 in group C; p < 0.001 in group A versus groups B or C). Overall postoperative morbidity rate was 33.13% in group A, 19.25% in group B, and 11.89% in group C, with significant difference in group A versus groups B or C (p = 0.002 and p < 0.001). Mean excess weight loss was significantly higher (72.7%) in group C versus group A (63.1%) (p = 0.015) at 12 months. CONCLUSIONS: Weight loss >5% prior to LRYGB may reduce morbidity, and preoperative weight loss >10% may improve weight loss outcomes at 1-year follow-up.

Outcome of patients with esophageal perforations: a multicenter study.

BACKGROUND: Recent studies have suggested that stent-grafting may improve the treatment outcome of patients with esophageal perforation, but evidence on this is still lacking. METHODS: Data on 194 patients who underwent conservative (43 patients), endoclip (4 patients) stent-grafting (63 patients) or surgical treatment (84 patients) for esophageal perforation were retrieved from nine medical centers. RESULTS: In-hospital/30-day mortality was 17.5 %. Three-year survival was 67.1 %. Age, coronary artery disease, and esophageal malignancy were independent predictors of early mortality. Chi squared automatic interaction detection analysis showed that patients without coronary artery disease, without esophageal malignancy and younger than 70 years had the lowest early mortality (4.1 %). Surgery was associated with slightly lower early mortality (conservative 23.3, endoclips 25.0 %, stent-grafting 19.0 %, surgery 13.1 %; p = 0.499). One center reported a series of more than 20 patients treated with stent-grafting which achieved an early mortality of 7.7 % (2/26 patients). Stent-grafting was associated with better survival with salvaged esophagus (conservative 76.7 %, endoclips 75.0 %, stent-grafting 77.8 %, surgery 56.0 %; p = 0.019). Propensity score adjusted analysis showed that stent-grafting achieved similar early mortality (p = 0.946), but significantly higher survival with salvaged esophagus than with surgical treatment (p = 0.001, OR 0.253, 95 % CI 0.110-0.585). Primary surgical repair was associated with somewhat lower early mortality (14.6 vs. 19.0 %; p = 0.561) and better survival with salvaged esophagus (85.4 vs. 77.8 %; p = 0.337) than stent-grafting. CONCLUSIONS: Esophageal perforation was associated with a rather high mortality rate in this all-comers population. Stent-grafting failed to decrease operative mortality, but it improved survival with salvaged esophagus. The results of one of the centers indicate that increasing experience with this less invasive procedure may possibly improve the outcome of these patients.

Mean fourteen-year, 100% follow-up of laparoscopic adjustable gastric banding for morbid obesity.

BACKGROUND: Many studies of short-term to mid-term outcomes after laparoscopic adjustable gastric banding (LAGB) have been published, but reliable long-term outcome reports with a minimum follow up ≥ 10 years in a sufficient number of included patients are still scarce. The objective of this study was to evaluate the long-term results after LAGB. METHODS: Sixty consecutive patients (44 women, 16 men) were treated for morbid obesity by LAGB between 1996 and 1999. Median age of the patients at the time of operation was 45 years (range 21-64). Median preoperative body mass index (BMI, kg/m(2)) was 45 (range 35-55). All patients were asked to adhere to a strict follow-up program. Patients' BMI and percentage excess weight loss (%EWL) were calculated in the hospital's database for bariatric patients, and excess weight was taken as the weight in kilograms above the weight at BMI of 25 kg/m(2). RESULTS: Complete data on all 60 patients could be assessed; thus, the overall rate of follow-up was 100%. After a median (range) follow-up of 14.1 years (13.2-16.8 years), the mean BMI (SD) dropped from 45 (5) to 36 (6) kg/m(2), with a mean (SD) EWL of 49% (29). At 15 years of follow-up, 29 (48%) bands have been removed, and 38 (63%) reoperations have been performed in 29 (48%) patients. Almost 70% received further treatment for their morbid obesity after band removal. Of those patients with the band still in place at 14 years, 40% had more than 50% EWL and 20% had less than 25% EWL. There was no mortality related to the primary or revisional operations, but 2 patients died of unrelated causes. CONCLUSIONS: Mean %EWL after LAGB after more than 14 years was fairly good-49%. However, a reoperation rate of more than 60% in 48% of the patients and a band removal rate of almost 50% may indicate that LAGB cannot be recommended as a primary procedure to the general morbidly obese population.

Fibrin glue and stents in the treatment of gastrojejunal leaks after laparoscopic gastric bypass: a case series and review of the literature.

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the most commonly performed bariatric/metabolic operation in Europe. Different treatment options for the management of gastrojejunal (GJ) leaks following LRYGB have been published. We looked at our own experience with GJ leaks after 645 consecutive LRYGB operations and reviewed the literature with focus on the use of fibrin sealant and self-expandable metal stents as treatment options. Patient data were prospectively collected in the hospital's database for bariatric patients. All patients with confirmed GJ leaks were reviewed. Patients with GJ leaks were actively treated by a combination of laparoscopic drainage and endoscopic fibrin sealant injections and/or stenting. Six patients (0.93%) have been treated for GJ leaks. All leaks were successfully treated and there was no leak-related mortality. The mean (SD) time for closure of the leaks and length of hospital stay was 19.5 days (6.2) and 23.2 days (3.7). The literature concerning endoscopic treatment options in case of GJ leaks following LRYGB operations is scarce and inconclusive. Immediate and active treatment with a combination of operative and endoscopic treatment options, rather than choosing only one treatment over another, may enhance the recovery process.

Physical discomfort due to redundant skin in post-bariatric surgery patients.

Massive weight loss after bariatric surgery leads to excess skin with functional and aesthetic impairments. The aim of this study was to evaluate the prevalence of excess skin after bariatric surgery and identify any relationship with pre- and postoperative characteristics. A total of 360 patients who had undergone bariatric surgery procedures were asked to complete a questionnaire designed by the surgical team at least 1 year after surgery. This questionnaire was planned to estimate any impairment due to redundant skin, which was graded according to a visual analogue scale (VAS, 0--0). Mean (standard deviation, SD) age of 110 males and 250 females was 51.2 (10.8) years. Mean preoperative body mass index (BMI) was 45.7 (6.4) kg m(-2) and mean postoperative BMI at follow-up was 33.6 (6.0) kg m(-2). After a mean follow-up of 56.1 (43.6) months, the mean weight loss was 35.2 (18.8) kg. Most patients (92.8%) reported problems with redundant skin, especially on the abdomen, upper arms and rear/buttocks, which impaired daily physical activity in half of them. Excess skin was associated with female gender (ß=-13.56, 95% confidence interval (CI) -16.81 to -10.32, p<0.0001), weight loss (ß=0.21, 95% CI 0.12-0.29, p<0.0001) and ΔBMI (ß=0.21, 95% CI 0.12-0.29, p<0.0001) at multivariate analysis. Patients with a ΔBMI>20 kg m(-2) showed a significantly surplus skin discomfort compared to ΔBMI≤5 and 5<ΔBMI≤10 (p<0.001). Patients with a weight loss>50 kg showed a significantly redundant skin discomfort compared to weight loss<20 kg (p<0.001). Weight loss after bariatric surgery reduces the medical risks of obesity but psychosocial and functional problems often remain due to the surplus skin. Our data suggest that a ΔBMI≤10 kg m(-2) and weight loss>20 kg, not BMI alone, might be taken into consideration as cut-off values for developing score systems with the intention to apply evidence-based indications for the surgical management of post-bariatric impairments.

SLEEVEPASS: a randomized prospective multicenter study comparing laparoscopic sleeve gastrectomy and gastric bypass in the treatment of morbid obesity: preliminary results.

BACKGROUND: The long-term efficacy of laparoscopic Roux-en-Y gastric bypass (RYGB) in the treatment of morbid obesity has been demonstrated. Laparoscopic sleeve gastrectomy (SG) as a single procedure has shown promising short-term results, but the long-term efficacy of SG has not yet been demonstrated. The aim of this study was to determine the preliminary 30-day morbidity and mortality of RYGB and SG in a prospective multicenter randomized setting. METHODS: A total of 240 morbidly obese (BMI = 35-66 kg/m²) patients evaluated by a multidisciplinary team were randomized to undergo either RYGB or SG. There were 117 patients in the RYGB group and 121 in the SG group; two patients had to be excluded after randomization. Both study groups were comparable regarding age, gender, BMI, and comorbidities. RESULTS: There was no 30-day mortality. The median operating time was significantly shorter in the SG group (66 min vs. 94 min, p < 0.001). All complications were recorded thoroughly. There were 7 (5.8 %) major complications following SG and 11 (9.4 %) after RYGB (p = 0.292). Nine (7.4 %) SG patients and 20 (17.1 %) RYGB patients had minor complications (p = 0.023). The overall morbidity was 13.2 % after SG and 26.5 % after RYGB (p = 0.010). There were three (2.5 %) early reoperations after SG and four (3.3 %) after RYGB (p = 0.719). CONCLUSIONS: At 30-day analysis SG is associated with a shorter operating time and fewer early minor complications compared to RYGB. There were no significant differences in major complications or early reoperations. Long-term follow-up is required to determine the effect on weight loss, resolution of obesity-related comorbidities, and improvement of quality of life.