Bariatric Revisionary Surgery for Failed or Complicated Vertical Banded Gastroplasty (VBG): Comparison of VBG Reoperation (re-VBG) versus Roux-en-Y Gastric Bypass-on-VBG (RYGB-on-VBG).

Background. Revision of failed bariatric procedures is a significant challenge for bariatric surgeons, because of the increasing number of recurring morbid obesity or complications, especially in patients with a previous Vertical Banded Gastroplasty (VBG). Methods. Since November 1998, 109 patients with failed or complicated VBG were followed in a retrospective study. 49 patients underwent re-VBG and, since 2004, 60 underwent Roux-en-Y Gastric Bypass-on-Vertical Banded Gastroplasty (RYGB-on-VBG). Results. At 3 years follow-up, mean BMI decreased from 37.4 to 31.2 Kg/m(2) in the first group, and from 35.0 to 28.4 Kg/m(2) in the second. Early complications were 7 (14.3%) in the first group and 4 (6.5%) in the second; late complications were 33 (59.1%) and 11 (18.3%), respectively. Conclusion. Although both operations seem to be effective as bariatric revision procedures in terms of BMI, the mid-term outcomes of RYGB-on-VBG demonstrate the lowest rate of complications and better quality of life.

Italian multicenter experience of Roux-en-Y gastric bypass on vertical banded gastroplasty: four-year results of effective and safe innovative procedure enabling traditional endoscopic and radiographic study of bypassed stomach and biliary tract.

BACKGROUND: Cancer, perforation, and bleeding in the bypassed stomach after Roux-en-Y gastric bypass (RYGB) are rare, but serious, complications that need an early diagnosis. Our goal was to perform gastric bypass such that traditional endoscopic and radiographic study of the gastric remnant would be possible and, at the same time, obtain results in terms of weight loss equivalent to those found after standard RYGB. A previously published study demonstrated that complete occlusion of the gastrogastric outlet was not necessary to lose weight. We have developed an open RYGB-on-vertical banded gastroplasty procedure. METHODS: Since 2002, 289 patients with a mean age of 40.1 +/- 14.8 years, mean body mass index of 51.4 +/- 7.3 kg/m(2), and mean percentage of excess body weight of 107.3% +/- 36.7% underwent RYGB-on-vertical banded gastroplasty as their primary procedure. RESULTS: The follow-up examinations included radiographic and, if necessary, endoscopic studies at 6 and 12 months postoperatively and annually thereafter. Two cases of anastomotic ulcer were detected, one of which involved band erosion. The percentage of excess weight loss was 48.2% +/- 18.8% after 6 months and 59.0% +/-17.7%, 63.3% +/- 13.9%, 66.9% +/- 17.5%, and 70.0% +/- 17.7% after 1, 2, 3, and 4 years, respectively. The weight loss curve was similar to that for standard RYGB. CONCLUSION: The results of our study have shown that RYGB-on-vertical banded gastroplasty is as effective as traditional RYGB, while allowing for traditional radiography of the bypassed stomach in every patient. Endoscopy of the distal stomach and, therefore, the biliary tract, was also possible. These are the fundamental aspects of the procedure.

Three-year results of Roux-en-Y gastric bypass-on-vertical banded gastroplasty: an effective and safe procedure which enables endoscopy and X-ray study of the stomach and biliary tract.

BACKGROUND: Cancer, perforation and bleeding in the bypassed stomach after RYGBP are rare but serious complications that require early diagnosis. Our goal was to perform a Roux-en-Y gastric bypass (RYGBP) whereby the traditional endoscopic and x-ray study of the bypassed stomach was possible, and at the same time obtain a good weight loss, similar to the standard RYGBP. We developed the RYGBP-on-Vertical banded gastroplasty (RYGBP on VBG), where a Goretex band surrounds the gastro-gastric outlet. METHODS: From June 2002 to September 2005, 128 patients, 94 female and 34 male, with age 50.5 +/- 14.8 SD years, BMI 51.6 +/- 7.2 SD kg/m2, and %EW 117.9 +/- 33.5 SD underwent RYGBP on VBG via an open approach. Radiological and, if necessary, endoscopic study has been carried out at 6 months, 1 year and then annually postoperatively. RESULTS: Two cases of anastomotic ulcer were detected, but no case of infection of the prosthetic material was found. Preoperative BMI fell from 51.6 +/- 7.2 to 38.1 +/- 6.6 after 6 months, to 35.0 +/- 7.1 after 1 year, to 34.4 +/- 6.1 after 2 years, and to 33.2 +/- 5.5 after 3 years. CONCLUSION: RYGBP on VBG was effective; the weight loss curve, compared to standard RYGBP, is similar, while allowing the traditional x-ray and endoscopy of the bypassed stomach and thus the biliary tract.

[Determinants of clinical priority and of actual waiting times for surgical interventions]. / Determinanti della priorità clinicà e dei tempi effettivi di attesa per interventi di chirurgia generale.

OBJECTIVES: To explore determinants of clinical priority and of actual waiting times for elective surgical interventions. DESIGN, SETTING PARTECIPANTS: 405 patients cared for at two general surgery wards, receiving an explicit judgement of clinical priority and whose actual waiting times to surgery were assessed. Clinicalpriority was assessed through 0 (no priority) to 10 (maximum priority). MAIN OUTCOME MEASURE: Identification through multivariate regression techniques of the clinical characteristics associated with high clinical priority (score 28) and with shorter actual waiting times. RESULTS: Patients with cancer, severe pain, relevant impairment in functional status and relevant expert improvement on quality and duration of survival were more frequently attributed a high clinical priority. As for waiting times, presence of cancer was the only factor associated with shorter waitings. Only for cancer patients high priority judgement was associated with shorter waiting times (median 21 vs. 69 days; p < 0.008). CONCLUSIONS: These findings suggest that actual waiting times are not influenced by the same clinical characteristics that clinicians value when assigning clinical priority. That may have some relevant implications on how waiting lists are managed, if consideration of relevant aspects of patients' needs are missed.

Radiological contrast studies after vertical banded gastroplasty (VBG) and Roux-en-Y gastric bypass (RYGBP) in patients with morbid obesity. Study of the complications.

PURPOSE: The aim of the study was to evaluate the role of radiological upper gastroenteric studies to detect early and postoperative complications after gastric restrictive surgery for obesity. MATERIALS AND METHODS: From October 1992 to October 2002, 650 patients submitted to vertical banded gastroplasty (VBG) and Roux-en-Y gastric bypass (RYGBP) underwent radiological follow-up to assess the presence of both early and late postoperative complications. The patients were 546 (84%) women and 104 (16%) men whose average weight was 125 kg (range: 78 to 218 kg). The average female age was 37 years (range: 17 to 69 years) and the average male age 36 (range: 19 to 64 years). Preoperative mean body mass index was 46 kg/m2 (range 31-78 kg/m2). The patients underwent radiological upper gastroenteric investigation employing water soluble contrast material between the 4th and 7th postoperative day. All patients underwent another late examination every year after surgery. RESULTS: At 10 years follow-up in 620 patients submitted to modified Mason VBG we observed the following early postoperative complications: 16 cases (2.6%) of oedema of the stoma, six cases (0.9%) of gastro-oesophageal reflux, one case (0.2%) of staple-line disruption, and one case (0.2%) of intragastric haemorrhage. Late complications in VBG included 26 cases (4.2%) of staple-line disruption, four cases (0.6%) of kinked stomas, six cases (0.9%) of pouch dilatations, two cases (0.4%) of stomal stenosis and one case (0.2%) of gastro-oesophageal reflux. In 30 RYGBP patients we observed the following early postoperative complications: one case (0.8%) of dilated pouch, one case (0.8%) of oedema of the anastomosis and one case (0.8%) of anastomotic leak. Late postoperative complications in the 30 RYGBP patients included three cases (2.5%) of stomal ulcers and one case (0.8%) of gastro-oesophageal reflux. We also examined the annual incidence of complications in late follow-up. DISCUSSION AND CONCLUSIONS: Both early and late radiological studies after gastric bariatric surgery enable the detection of postoperative complications and provided morphological and volumetric data after VBG and RYGBP. Post-operative complications (gastric perforation, stomal stenosis, etc.) need to be emphasised and the clinical approach modified to enable suitable weight loss.

A functional Roux-en-Y gastric bypass to avoid gastric exclusion: 1-year results.

BACKGROUND: Roux-en-Y gastric bypass (RYGBP) is rarely performed in Italy because it involves gastric exclusion. RYGBP with the stomach partitioned by an adjustable gastric band has been previously described. We have developed a functional RYGBP (FRYGBP) where an adjustable band allows access from a stapled gastric bypass pouch into the distal stomach. METHODS: From October 2001 to May 2002, 16 patients underwent FRYGBP. A 30-cc vertical gastric pouch was fashioned by a 25-mm circular and 90-mm four-row stapler as in the Mason VBG. A hand-sewn retrocolic gastroenterostomy with 150-cm Roux and 30-cm afferent limbs completed the operation. The pouch outlet was encircled distal to the gastrojejunostomy by a non-inflated adjustable gastric band. The bands were inflated at 1 month during barium swallow, to demonstrate occlusion of the gastro-gastric outlet and patency of the gastrojejunostomy. RESULTS: There was no operative mortality. After 1 year, mean percent excess BMI loss (%EBMIL) was 71.2 +/- 16.2% (SD), and gastroscopy of the bypassed stomach was possible on 81% of the patients. There were three asymptomatic late complications (19%): two band erosions, converted to RYGBP, and one stenosis of the gastro-gastric outlet. CONCLUSION: FRYGBP thus far has been effective and allows the study of the excluded stomach. This ongoing study will undergo long-term evaluation.