Management of the Postbariatric Medial Thigh Deformity.

BACKGROUND: Thigh contour deformities-in particular, those of the medial thighs-are a common concern for many individuals seeking body contouring. Despite the frequency of this concern, some plastic surgeons have often been reluctant to embrace the medial thigh-lift procedure because of the risk for significant complications and relatively poor results. The authors' approach to medial thigh contouring is to address the variables outside of the medial thighs affecting the medial thighs before considering a medial thigh-lift procedure with a vertical component. In this article, the authors review the senior author's (J.F.C.) experience of 350 vertical medial thigh lifts in the weight-loss patient. METHODS: The charts of 350 consecutive individuals who had undergone vertical medial thigh lifts were reviewed for complications and other variables. The procedures were all performed by the senior author between February of 2000 and February of 2014. The preoperative markings, current surgical technique, and postoperative care are described. RESULTS: There were 326 women and 24 men in the study, with an average age of 43 years. The overall complication rate was 45.14 percent. Skin dehiscence and seroma formation were the most frequent complications, at 31.14 percent and 18.18 percent, respectively. The vast majority of patients were pleased with the aesthetic and functional results of their surgery. CONCLUSION: The medial thigh deformities of the weight-loss patient are effectively addressed by a vertical medial thigh lift when the variables adjacent to the medial thighs are first treated by a body lift. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The vertical medial thigh lift.

This article discusses management of the post-weight loss thigh deformity. Beginning with an explanation of the soft tissue variables contributing to the thigh and medial thigh deformity in the postbariatric individual, the article describes the important elements of selecting and screening candidates for surgery and the ideal sequence of procedures that should be followed to optimize results in this patient population. A detailed step-by-step description of the author's technique for medial thigh lift is provided along with multiple examples of outcomes. Aftercare is reviewed along with potential complications and their management.

An analysis of gastric pouch anatomy in bariatric surgery.

BACKGROUND: The goal of most bariatric surgeons has been to construct small volume pouches in the proximal stomach to restrict the intake of food. The purpose of this study is to demonstrate that in addition to pouch volume, specific gastric pouch anatomy plays a significant role in weight loss. MATERIALS AND METHODS: The physical properties and dynamics of the pouch in our form of gastric bypass were compared with those in the most commonly performed bariatric procedures by creating a model. Our weight loss data were reviewed and compared with data reported in the literature. RESULTS: According to LaPlace's and Poiseulle's Laws, a long narrow cylinder will have less wall tension and slower flow rate of material than a wider cylinder. Bariatric procedures with narrow pouches appear to produce better weight loss. CONCLUSIONS: Long narrow pouches should have less tendency to enlarge and should delay the transit of material to a greater degree than wider pouches according to the LaPlace's and Poiseuille's Laws. Our data and the data of others strongly suggest that long narrow pouches are the most effective operations in bariatric surgery.

Body lift.

The body in the patient who has lost a massive amount of weight presents an extreme form of traditional esthetic and functional body contour concerns. Routine body contouring procedures usually produce only suboptimal results in this patient population. The body lift described herein is an excellent alternative to treat the body contour deformity of the patient who has undergone bariatric surgery. As with every technique, careful patient selection, education, and preparation are critical to minimizing complications and optimizing outcome.

Reducing the incidence of incisional hernias following open gastric bypass surgery.

BACKGROUND: Abdominal wall hernias are a common complication following open gastric bypass (RYGBP) surgery. In an effort to reduce the incidence of incisional hernias with our form of open RYGBP, progressively smaller, upper midline epigastric incisions have been utilized along with permanent sutures. The purpose of this study is to analyze whether incision location, size and choice of suture material affect the incidence of incisional hernias following open RYGBP. METHODS: Clinically evident incisional hernias and other wound complications and non-wound related complications were analyzed for 1,180 consecutive primary open proximal RYGBP procedures performed between August 2002 and June 2006. Progressively smaller, upper midline incisions were utilized during the time period of the study. RESULTS: Smaller incisions limited to the upper abdomen and approximated with permanent sutures were associated with significantly fewer hernias (P<0.01), wound dehiscences (P<0.03), eviscerations (P<0.03) and wound infections (P<0.03). Smaller incisions may also be associated with less postoperative discomfort. CONCLUSION: A reduction in incision size, the avoidance of the periumbilical region and the use of nonabsorbable sutures has significantly reduced the incidence of incisional hernias and acute fascial disruptions with our form of open RYGBP. These findings are consistent with LaPlace's law regarding wall tension and vessel radius. In addition, we found smaller incisions to be associated with fewer infections and seromas and less postoperative discomfort. A reduction in incision size has not been associated with an increase in morbidity or mortality or changes in the operative time.

Bowel obstruction after open and laparoscopic gastric bypass surgery for morbid obesity.

BACKGROUND: Bowel obstruction is increasingly recognized as an important complication after gastric bypass. This study analyzed late bowel obstruction after open and laparoscopic gastric bypass surgery. STUDY DESIGN: The medical records of 1,378 patients who had proximal gastric bypass during the years 2002 and 2003 at a large bariatric center were evaluated for readmission with bowel obstruction requiring operations. In the study group, 697 patients underwent a laparoscopic approach and 735 had an open approach to gastric bypass. Patients had a minimum followup of 18 months. RESULTS: In the laparoscopic group, 68 of the 697 patients were readmitted for bowel obstruction requiring operations, for an incidence of 9.7%. There were 14 additional recurrent obstructions, for a total of 82 operations. Of the 68 patients requiring reoperations, 3 (4.4%) required bowel resection and 8 (11.7%) had conversion to an open approach. Bowel resections were performed in two of the three patients with a second episode of bowel obstruction. The average time intervals between the primary operation in 2002 and 2003 and the first episode of obstruction were 511 and 385 days, respectively. There were no readmissions requiring operations for late bowel obstruction in the open gastric bypass group. CONCLUSIONS: We found an unanticipated high incidence of bowel obstruction after laparoscopic gastric bypass surgery. There were no hospital admissions for bowel obstruction requiring operations in the open gastric bypass group. Lack of adhesions and the resulting free displacement of small bowel after laparoscopy appear to be the cause of this complication. Open gastric bypass surgery produces thin, diffuse upper abdominal adhesions that may then stabilize the bowel and prevent internal hernias and bowel obstruction. An open approach may be a reasonable option for management of recurrent episodes of bowel obstruction after laparoscopy.

Body lift: an account of 200 consecutive cases in the massive weight loss patient.

BACKGROUND: The epidemic of obesity in the United States has led to a rapid increase in the number of bariatric procedures performed over the past several years. The dramatic changes to the torso following massive weight loss are only partially addressed by routine procedures such as abdominoplasty and liposuction. Circumferential body lifts or simultaneous abdominoplasty, thigh, and buttock lifts are becoming the method of choice for treating the postbariatric condition. In this article, the authors review the senior author's experience of 200 body lifts with massive weight loss individuals. METHODS: The charts of 200 consecutive body lift patients were reviewed for complications and other variables. The preoperative markings, current surgical technique, and postoperative care are described. The patients were classified into three types according to their body mass index at the time of surgery. Type I individuals had a body mass index less than 28, type II individuals had a body mass index between 28 and 32, and type III individuals had a body mass index greater than 32. RESULTS: Type I and II patients in many instances achieved a nearly ideal body contour. Type II and III individuals also had a significant functional and aesthetic improvement but were more likely to have complications. The overall complication rate was 50.0 percent. The most frequent complications were skin dehiscence and seroma formation at 32.5 percent and 16.5 percent, respectively. CONCLUSIONS: The body lift very effectively addresses the functional and aesthetic concerns of the massive weight loss patient. Careful patient selection and education are essential to a good outcome.

The learning curve measured by operating times for laparoscopic and open gastric bypass: roles of surgeon's experience, institutional experience, body mass index and fellowship training.

BACKGROUND: Surgeons must overcome a substantial learning curve before mastering laparoscopic Roux-en-Y gastric bypass (LRYGBP). This learning curve can be defined in terms of mortality, morbidity or length of surgery. The aim of this study was to compare the learning curves in terms of surgical time for the first 3 surgeons performing LRYGBP in our hospital with the length of surgery for open gastric bypass (CONTROLS). METHODS: We compared 494 primary LRYGBPs performed by 3 surgeons (393 by 1st SURGEON, 57 by 2nd SURGEON and 44 by 3rd SURGEON) to 159 open vertical banded gastroplasty-Roux-en-Y gastric bypasses (CONTROLS). Data for LRYGBP patients were prospectively obtained. Factors that significantly affected the length of surgery were identified by univariate and multivariate linear regression analysis. RESULTS: LRYGBP and CONTROL patients were similar in age, height, weight and BMI, although more CONTROLS were male. Median time for the 1st SURGEON performing LRYGBP dropped for each subsequent 100 operations: 1st 100 - 190 min, 2nd 100 - 135 min, 3rd 100 - 110 min and 4th 100 - 100 min. Median time for 2nd SURGEON performing LRYGBP was 120 min, 3rd SURGEON 173 min and CONTROLS 64 min. Length of surgery significantly correlated with surgical experience in terms of numbers of operations and BMI of patient. Times for 2nd SURGEON, a fellowship trained laparoscopic surgeon, started significantly faster than 1st SURGEON's, but did not significantly improve with experience. 3rd SURGEON's initial times were similar to 1st SURGEON's, but his times improved more rapidly with experience. Times for CONTROLS were significantly faster than all laparoscopic groups and did not correlate with operation number or patient BMI. CONCLUSIONS: The length of surgery for LRYGBPs continued to shorten beyond 400 operations for the first surgeon performing LRYGBP in our hospital. Previous fellowship training in LRYGBP shortened surgical times during initial clinical experience as an attending for the second surgeon. The learning curve was truncated because of the already established LRYGBP program.

Predictors of prolonged hospital stay following open and laparoscopic gastric bypass for morbid obesity: body mass index, length of surgery, sleep apnea, asthma, and the metabolic syndrome.

BACKGROUND: The number of weight reduction operations performed for type II and type III obesity is rapidly escalating. Risk of surgery has been infrequently stratified for patient subgroups. The purpose of this study was to identify patient characteristics that increased the odds of a prolonged hospital length of stay (LOS) following open or laparoscopic Roux-en-Y gastric bypass (RYGBP). METHODS: The hospital records of 311 patients who underwent RYGBP in a 6-month period were retrospectively reviewed. Patient characteristics including the presence of significant obesity-related medical conditions were recorded. Analysis was based on intent to treat. Univariate and step-wise logistic regression analysis was used to identify the odds ratio (OR) and adjusted odds ratio (AOR) for predictors of an increased hospital LOS. RESULTS: Datasets for 311 patients were complete.159 patients underwent open vertical banded gastro-plasty-Roux-en-Y gastric bypass (VBG-RYGBP) and152 laparoscopic RYGBP (LRYGBP). 78% of patients were female. Median age was 40 years (range 18-68). Median BMI was 49 kg/m2 (range 35-82). 17% of patients had sleep apnea, 18% asthma, 19% type 2 diabetes, 13% hypercholesterolemia and 44% hypertension. Median length of surgery for open VBG-RYGBP (64 minutes) was significantly faster than forLRYGBP (105 minutes). Median length of stay was significantly shorter for LRYGBP (2 days) than openVBG-RYGBP (3 days). Univariate logistic regression analysis identified 6 predictors of increased LOS:open surgery (0.4 OR); increasing BMI (60 kg/m2 0.38 OR; BMI 70 kg/m2 0.53 OR); increasing length of surgery (120 min 0.33 OR; 180 min 0.48 OR); sleep apnea (2.25 OR); asthma (3.73 OR); and hypercholesterolemia (3.73 OR). Subset analysis identified patients with the greatest odds for a prolonged hospital stay: women with asthma (2.47 AOR) or coronary artery disease (8.65 AOR); men with sleep apnea (5.54 OR) or the metabolic syndrome (6.67-10.20 OR); and patients undergoing a laparoscopic operation with sleep apnea (11.53 AOR) or coronary artery disease(12.15 AOR). CONCLUSIONS: Open surgery, BMI, length of surgery,sleep apnea, asthma and hypercholesterolemia all increased the odds of a prolonged LOS. Patients with the greatest odds of long LOS were women with asthma or coronary disease, men with sleep apnea or the metabolic syndrome, and patients undergoing laparoscopic surgery with sleep apnea or coronary artery disease. Patients at high-risk for prolonged hospital stay can be identified before undergoingRYGBP. Surgeons may wish to avoid high-risk patients early in their bariatric surgery experience.

Bariatric surgery in adolescence. is this the best age to operate?

BACKGROUND: Bariatric surgery in morbidly obese adolescents is controversial. Many argue that morbidly obese individuals should be of adult age before undergoing bariatric operations, despite the progressive and debilitating course of this increasingly common disease. MATERIALS AND METHODS: 19 consecutive adolescent patients, aged 13-17, underwent vertical banded gastroplasty-Roux-en-Y gastric bypass between May 1990 and August 2001. Average BMI was 49 kg/m(2), range 38-67. All had one or more co-morbidities. Follow-up was obtained up to 10 years. RESULTS: Postoperative BMI at the maximum time of follow-up, mean 5.5 years (range 1-10 years), was 28 (range 23 to 45). Only one patient did not lose enough weight and was considered a failure. There were two revisions and no mortality or morbidity. All co-morbidities disappeared. Family and patients were pleased with the surgery. CONCLUSIONS: Early surgical intervention should be offered to a greater number of adolescents to minimize the emotional and physical consequences of morbid obesity.

An assessment of vertical banded gastroplasty-Roux-en-Y gastric bypass for the treatment of morbid obesity.

OBJECTIVE: To analyze retrospectively the mortality, morbidity, and weight loss of a specific form of gastric bypass for the treatment of morbid obesity. The technique incorporates a small pouch along the lesser curvature of the stomach, an outlet restricted by a nondistensible band and a Roux-en-Y gastric bypass. MATERIAL AND METHODS: We analyzed 652 consecutive patients with no previous bariatric surgery who underwent our present form of gastric bypass. Parameters used to evaluate the technique included mortality, weight loss at 5 years and complications. The operation is a combination of vertical banded gastroplasty and Roux-en-Y gastric bypass (VBG-RGB). The patients followed up to 5 years had an initial weight of 140 kg [range, 94 to 288] and a BMI of 50 [range, 38 to 86]. Superobese individuals (BMI of 60 [range, 48 to 86]) made up 42% of the group. RESULTS: There was an early reoperation rate of 0.5%. The incidence of late complications that required reoperation was 0.5%. There were 2 deaths in the study from pulmonary embolism for a mortality of 0.3%. At 5 years, the patients had lost an average of 58kg [range, 14 to 143] and had a percentage excess weight loss of 77 [range, 32 to 108]. Their BMI was reduced to 29 kg/m(2) [range, 20 to 43] and 93% lost more than 50% of the excess weight. CONCLUSIONS: VBG-RGB is effective in producing superior weight loss in morbid and superobese patients and has a low mortality and morbidity. We recommend this procedure without reservations.