Meal size, satiety and cholecystokinin in gastrectomized humans.

A wealth of data supports the idea that the stomach and cholecystokinin octapeptide (CCK-8) normally play important roles in meal size and satiety. We studied long-term gastrectomized humans to further evaluate this possibility. Ten humans, who were gastrectomized 8 (3-12) years earlier, and eight controls ate a meal from a plate placed on a scale connected to a computer and estimated their satiety every minute using a computerized rating scale. Blood levels of CCK-8 were measured before and after the meal. There was no difference between the groups in the amount of food consumed or in the perception of satiety during the meal. Gastrectomized humans had higher blood levels of CCK-8 than controls before the meal; the levels increased after the meal in the controls but not in the gastrectomized subjects. It is suggested that although the stomach and CCK-8 normally are involved in the control of meal size and satiety, their roles are dispensable.

A pilot study of long-term effects of a novel obesity treatment: omentectomy in connection with adjustable gastric banding.

AIM: To determine whether visceral fat reduction in connection with bariatric surgery could improve weight loss and metabolic profile of obese subjects. PATIENTS AND METHODS: In a one-center, randomized and controlled pilot trial we assigned 50 subjects with severe obesity (body mass index >35 kg/m(2)) to either adjustable gastric banding (AGB) alone (11 men and 14 women), or AGB plus surgical removal of the total greater omentum (11 men and 14 women). The patients were followed at regular intervals for 2 y and examined at 0 and 24 months with respect to body composition and metabolic profile. RESULTS: No significant differences between control and omentectomized patients were observed at baseline. The removed greater omentum constituted 0.8+/-0.4% (mean+/-s.d.) of total body fat. At 2 y follow-up there was an expected decrease in body weight and an improvement in metabolic profile in both groups. Although omentectomized subjects tended to lose more weight than control subjects the difference was not statistically significant and changes in waist-to-hip ratio and saggital diameter did not differ between groups. However, the improvements in oral glucose tolerance, insulin sensitivity and fasting plasma glucose and insulin were 2-3 times greater in omentectomized as compared to control subjects (P from 0.009 to 0.04), which was statistically independent of the loss in body mass index. No differences in blood lipids between the groups were recorded. No adverse effects related to omentectomy were observed. CONCLUSIONS: Omentectomy, when performed together with AGB, has significant positive and long-term effects on the glucose and insulin metabolic profiles in obese subjects.

Recurrence after colectomy in Crohn's colitis.

PURPOSE: Previous studies on recurrence and reoperation after colectomy in Crohn's colitis have been based on heterogeneous groups of patients, and divergent findings may be explained by referral biases and small numbers of patients. The aim of this study was to account for recurrence rates, present risk factors for recurrence after primary colectomy, and account for the ultimate risk of having a stoma after colectomy with ileorectal anastomosis in patients with Crohn's colitis. METHODS: Data on the primary resection, postoperative recurrence, influence of concomitant risk factors, frequency of stoma operations and proctectomy were evaluated retrospectively using multivariate analysis in a population-based cohort of 833 patients with Crohn's colitis. RESULTS: The cumulative 10-year risk of a symptomatic recurrence was 58 percent (95 percent confidence interval, 53-63 percent) and 47 percent (95 percent confidence interval, 42-52 percent), respectively, after colectomy with ileorectal anastomosis and segmental colonic resection. In colectomy with ileostomy, lower rates were found with respectively 24 percent (95 percent confidence interval, 18-30 percent) and 37 percent (95 percent confidence interval, 32-43 percent) after subtotal colectomy and proctocolectomy with ileostomy. The multivariate analysis showed that perianal disease, ileorectal anastomosis, and segmental resection were independent risk factors for postoperative recurrence. In 76 percent of patients with ileorectal anastomosis, a stoma-free function could be retained during a median follow-up of 12.5 years. CONCLUSION: Colectomy with ileorectal anastomosis or segmental resection is a feasible option in the surgical treatment of Crohn's colitis, although anastomoses, in addition to perianal disease, carry an increased risk of recurrent disease.

Risk factors for surgery and recurrence in 907 patients with primary ileocaecal Crohn's disease.

BACKGROUND: Previous studies on risk factors for resection and postoperative recurrence in Crohn's disease have given inconclusive results. The aim of this study was to assess the risk for resection and postoperative recurrence in the treatment of ileocaecal Crohn's disease and to define factors affecting the course of the disease. METHODS: A population-based cohort of 907 patients with primary ileocaecal Crohn's disease was reviewed retrospectively. RESULTS: Resection rates were 61, 77 and 83 per cent at 1, 5 and 10 years respectively after the diagnosis. Relapse rates were 28 and 36 per cent 5 and 10 years after the first resection. A younger age at diagnosis resulted in a low resection rate. The presence of perianal Crohn's disease and long resection segments increased the incidence of recurrence, and resection for a palpable mass and/or abscess decreased the recurrence rate. A decrease in recurrence rate during the study period (1955-1989) was observed. CONCLUSION: In ileocaecal Crohn's disease the probability of resection is high and the risk of recurrence moderate. Crohn's disease in childhood carries a lower risk of primary resection. Perianal disease and extensive ileal resection increase the risk of recurrence.

Risk factors for surgery and postoperative recurrence in Crohn's disease.

OBJECTIVE: To assess the impact of possible risk factors on intestinal resection and postoperative recurrence in Crohn's disease (CD) and to evaluate the disease course. SUMMARY BACKGROUND DATA: The results of previous studies on possible risk factors for surgery and recurrence in Crohn's disease have been inconsistent. Varying findings may be explained by referral biases and small numbers of patients in some studies. METHODS: Data on initial intestinal resection and postoperative recurrence were evaluated retrospectively in a population-based cohort of 1,936 patients. The influence of concomitant risk factors was assessed using uni- and multivariate analyses. RESULTS: The cumulative rate of intestinal resection was 44%, 61%, and 71% at 1, 5, and 10 years after diagnosis. Postoperative recurrences occurred in 33% and 44% at 5 and 10 years after resection. The relative risk of surgery was increased in patients with CD involving any part of the small bowel, in those having perianal fistulas, and in those who were 45 to 59 years of age at diagnosis. Female gender and perianal fistulas, as well as small bowel and continuous ileocolonic disease, increase the relative risk of recurrence. CONCLUSIONS: Three of four patients with CD will undergo an intestinal resection; half of them will ultimately relapse. The extent of disease at diagnosis and the presence of perianal fistulas have an impact on the risk of surgery and the risk of postoperative recurrence. Women run a higher risk of postoperative recurrence than men. The frequency of surgery has decreased over time, but the postoperative relapse rate remains unchanged.

Increased risk of cancer in ulcerative colitis: a population-based cohort study.

OBJECTIVE: There is an increased risk of colorectal cancer among patients with ulcerative colitis (UC). However, the overall and site specific cancer risks in these patients have been investigated to a limited extent. To study the association between UC and cancer, a population-based study of 1547 patients with UC in Stockholm diagnosed between 1955 and 1984 was carried out. METHODS: The patients were followed in both the National Cancer Register and the National Cause of Death Register until 1989. For comparisons, regional cancer incidence rates in Stockholm County were used together with individually computed person-years at risk in the UC disease cohort. RESULTS: A total of 121 malignancies occurred among 97 individuals as compared with 89.8 expected (standardized morbidity ratio [SMR] = 1.4; 95% confidence interval (CI), 1.1-1.6). Overall, an excess number of colorectal cancers (SMR, 4.1; 95% CI, 2.7-5.8), and hepatobiliary cancers in men (SMR = 6.0; 95% CI, 2.8-11.1) associated with primary sclerosing cholangitis, was observed. The risk of pulmonary cancer was decreased (SMR = 0.3; 95% CI, 0.1-0.9). In all, 91 extracolonic malignancies were observed, compared with the 82.3 expected (SMR = 1.11; 95% CI, 0.9-1.3). CONCLUSIONS: In UC patients, the overall cancer incidence is increased mainly because of an increased incidence of colorectal and hepatobiliary cancer. This increase is partly counterbalanced by a decreased risk of pulmonary cancer compared with that in the general population.

Complications following Swedish adjustable gastric banding: a long-term follow-up.

BACKGROUND: The Swedish adjustable gastric band (SAGB) has been in use since 1985. The aim of this study was to analyze short and long-term complications linked to the SAGB. MATERIALS AND METHODS: Between August 1990 and December 1996, we operated on a series of 326 patients (78 men and 248 women) at the Huddinge University Hospital and the Norra Alvsborg County Hospital. The mean age of patients at surgery was 40 years (range 19-62). The mean preoperative weight was 125 kg (range 81-181). The mean excess weight was 80%. RESULTS: The mean time of follow-up was 28 months (range 6-76). Complications requiring reoperation included two (0.6%) band dislocations, six (1.8%) band leakages, and 16 (4.6%) band migrations-erosions. The most common reason for abdominal reoperation, band migration, was attributed to overfilling of the band system. In the patients in whom migration occurred, the bands had been filled with a mean volume of 12.6 ml fluid. In the remaining patients, the mean volume was 8.7 ml. The most common complication not requiring reoperation was reflux disease (4.7%). In cases with a small pouch, this complication did not seem to be a serious problem. The mean excess weight loss in the 296 patients without complications was 68%. CONCLUSION: The overall long-term complication rate following SAGB is reasonable. With improved operating technique and closer follow-up, it should be possible to reduce the complication rate further. Reoperation because of band migration appears to be related to overfilling of the system and should therefore be avoidable in most cases.

Oral budesonide for prevention of postsurgical recurrence in Crohn's disease. The IOIBD Budesonide Study Group.

BACKGROUND & AIMS: Prevention of postoperative recurrence after resection for Crohn's disease (CD) would be of great clinical benefit. The efficacy of oral budesonide for prevention of endoscopic recurrence was evaluated in patients undergoing resection for ileal or ileocecal CD. METHODS: Sixty-three patients received budesonide and 66 received placebo in a double-blind, randomized trial with parallel groups. Ileocolonoscopy, including biopsy, was performed after 3 and 12 months. Indications for surgery were fibrostenosis (78 patients), disease activity (41), and other reasons (10). RESULTS: The frequency of endoscopic recurrence did not differ between the groups at 3 and 12 months. In patients with disease activity as indication for surgery, the endoscopic recurrence rate at the anastomosis was lower in the budesonide group at 3 months, although not significantly (21% vs. 47%; P = 0.11), and at 12 months (32% vs. 65%; P = 0.047). There was no such difference with respect to fibrostenosis as indication for surgery. No differences in adverse event patterns were found between the two groups. CONCLUSIONS: Oral budesonide, 6 mg daily, offered no benefit in prevention of endoscopic recurrence after surgery for ileal/ileocecal fibrostenotic CD but decreased the recurrence rate in patients who had undergone surgery for disease activity.

Clinical course of colorectal Crohn's disease: a 35-year follow-up study of 507 patients.

BACKGROUND & AIMS: Crohn's disease (CD) confined to the colon and rectum is an increasing clinical entity. The aim of this study was to assess the features and clinical course of colorectal CD. METHODS: This was a retrospective cohort study of 507 patients in whom colonic or rectal CD had been diagnosed between 1955 and 1989. RESULTS: Colonic distribution was segmental in 40%, total in 31%, and left-sided in 26%. Perianal/rectal fistulas occurred in 37%. In patients who attained clinical remission, the 5-year cumulative relapse rate after diagnosis was 67% (95% confidence interval [CI], 62-72). At the initial presentation of CD, the frequency of major surgery decreased from 24% to 14% (P < 0.005) over time. Still, the overall long-term probability of major surgery after 10 years was unaltered (49% vs. 47%). The presence of fistulas increased the probability of surgical resection (relative risk [RR], 1.7 [95% CI, 1.3-2.2]), whereas left-sided disease was associated with a decrease (RR, 0.6 [95% CI, 0.4-0.8]). Twenty-four percent of the patients developed inflammation in the small bowel. The cumulative risk for a permanent ileostomy was 25% (95% CI, 21-29) 10 years after diagnosis. CONCLUSIONS: Colorectal CD is an increasing entity carrying substantial morbidity. Half of the patients will undergo surgical resection within the first 10 years, and half of those will ultimately undergo ileostomy. Changed management at diagnosis has not affected the long-term probability of resection.

Incidence of Crohn's disease in Stockholm County 1955-1989.

AIM: To evaluate the incidence of Crohn's disease in Stockholm County between 1955 and 1989. METHODS: A cohort of 1936 patients with Crohn's disease was retrospectively assembled. Incidence rates and changes in disease distribution were assessed. RESULTS: The mean increase in incidence was 15% (95% confidence intervals 12% to 18%) per five year period with a mean annual incidence rate at 4.6/10(5) during the last two decades. The mean incidence for the entire study period was similar for men and women. The mean age at diagnosis increased from 25 years in 1960-64 to 32 years in 1985-89, partly because of an increasing proportion of patients aged at least 60 years at diagnosis. The proportion of patients with colonic Crohn's disease at the time of diagnosis increased from 15% to 32% (17% difference; 95% confidence intervals 12% to 23%) whereas the proportion of patients with ileocaecal disease decreased from 58% to 41% (17% difference; 95% confidence intervals 10% to 24%) during the study period. Elderly patients had a higher proportion of small bowel disease and a lower proportion of ileocolonic disease compared with the younger patients. CONCLUSION: The incidence rate of Crohn's disease in Stockholm has stabilised at 4.6/10(5) and the proportion of elderly patients has increased during a 35 year period. Colonic Crohn's disease has increased in frequency with a reciprocal decrease in ileocaecal disease.

The Swedish Adjustable Gastric Banding (SAGB) for morbid obesity: 9 year experience and a 4-year follow-up of patients operated with a new adjustable band.

BACKGROUND: We have developed an adjustable gastric band in which the stoma diameter can be adjusted from the outside. A standardized technique was employed and the application of our band in terms of weight loss and complication rate was evaluated METHODS: Between August 1990 and November 1991, 50 patients (15 men and 35 women) were operated on by laparotomy. Their mean age at surgery was 41 (19-60) years. Mean preoperative weight was 134 (106-181) kg and the mean BMI was 46 kg/m2 (range 33-59 kg/m2). RESULTS: No patient was lost to follow-up. Four were excluded from the study (brain tumor, pregnancy and two reoperations). The remaining 46 were followed for at least 4 years. At follow-up, mean weight was 80 kg and mean BMI was 27.5 kg/m2. The patients had lost a mean of 54 kg. Two patients (4%) had abdominal reoperation because of technical problems. There was one incisional hernia and one minor wound infection, but no other significant complications. CONCLUSION: This relatively simple method appears to be at least as good as the other operations, and weight loss can be adjusted to patient comfort. Currently, the procedure is being performed laparoscopically.

Variation in adrenergic regulation of lipolysis between omental and subcutaneous adipocytes from obese and non-obese men.

Regional variations in adipocyte lipolysis between subcutaneous and visceral fat may be important for obesity complications. In the present study, we compared adrenergic regulation of lipolysis in omental and subcutaneous adipocytes from obese (n = 15) and non-obese (n = 14) male subjects. Waist-to-hip ratio, blood pressure, plasma insulin, and plasma triglycerides were increased in obesity. No regional differences in adrenoceptor lipolytic function were observed in non-obese subjects with the exception of a slight increase in noradrenaline sensitivity in omental adipocytes (P < 0.05), because of increased beta(1)-adrenoceptor sensitivity (P < 0.05). In the obese subjects, the rate of noradrenaline-induced glycerol release was 2-fold higher (P < 0.005) and the noradrenaline sensitivity was 3-fold higher (P < 0.05) in omental versus subcutaneous adipocytes. These findings were mainly due to a 50-fold increase in omental beta(3)-adrenoceptor sensitivity (P < 0.002) and to a smaller 6-fold increase in omental beta(1)-adrenoceptor sensitivity (P < 0.02), accompanied by increased beta(3)- as well as beta(1)-adrenoceptor lipolytic rates at approximately 50% receptor subtype occupancy by the agonist (P < 0.05). In conclusion, minor regional differences in adipocyte lipolytic response to catecholamines are present in non-obese males. In contrast, catecholamine-induced lipolysis is markedly increased in omental as compared to subcutaneous adipocytes in obese males, mainly due to an increase in beta(3)-adrenoceptor function of visceral fat cells, in combination with a smaller increase in beta(1)-adrenoceptor function.

Validation of Pouch Size Measurement Following the Swedish Adjustable Gastric Banding Using Endoscopy, MRI and Barium Swallow.

BACKGROUND: Pouch volume appears to be of major importance for subsequent weight loss following any gastric restriction type of surgery for morbid obesity. In order to be able to evaluate pouch volume following Swedish Adjustable Gastric Banding (SAGB), an endoscopic pouch volume classification system was designed in which pouch volume is classified in five categories. The aim of this study was to validate the endoscopic classification system using MRI and barium swallow as reference methods for pouch volume measurement. METHODS: Twenty patients (13 women and seven men) were operated for obesity with SAGB. They were investigated a mean of 3 years (6 weeks-5.5 years) after surgery and had at that time lost a mean of 60 (12-112) kg. During the same afternoon they sequentially underwent endoscopy, MRI and barium swallow with an empty stomach. RESULTS: The mean pouch volume measured with MRI was 70 ml (0-1 80 ml) and with barium swallow was 72 ml (0-1 95 ml). In 17/20 patients the volume as measured by MRI and barium swallow was in the same volume category as with endoscopy. The correlation measured according to Pearson was significant between endoscopy on one hand and MRV barium swallow both independently and together (p < 0.001). CONCLUSION: Based on these results we are confident in using our endoscopic classification system for postoperative follow-up of pouch volume.

Pouchitis following pelvic pouch operation for ulcerative colitis. Incidence, cumulative risk, and risk factors.

AIM: This study was undertaken to assess the risk for pouchitis in patients with ulcerative colitis who underwent surgery with colectomy, restorative pelvic pouch, and ileoanal anastomosis and to evaluate possible factors predictive for pouchitis development. PATIENTS AND METHODS: All patients receiving a pelvic pouch because of ulcerative colitis at Huddinge University Hospital between 1980 and 1993 (n = 149; 89 men) were prospectively evaluated for symptoms suggestive of pouchitis. Diagnosis of pouchitis was based on occurrence of certain symptoms in combination with endoscopic findings. Pouchitis was divided into mild and severe, and the time span until the first attack of mild or severe pouchitis was calculated for each patient. RESULTS: Median follow-up time was 54 (5-152) months. The absolute cumulative risk of developing mild pouchitis was 21, 26, and 39 percent at 6, 12, and 48 months, respectively. The corresponding cumulative risk of developing severe pouchitis was 9, 11, and 14 percent, respectively. Risk for both groups together was 51 percent at 48 months. The occurrence of pouchitis, calculated at six-month intervals after closure of the loop ileostomy, was highest (23.1 percent) during the first six months. Incidence during the next six-month period was 11.4 percent and then only 3.1 percent thereafter. Thirty-two patients (21.5 percent) had chronic continuous symptoms requiring long-term metronidazole treatment, and 14 (9.4 percent) of those had chronic severe pouchitis. In two patients, removal of the pouch and permanent ileostomy became necessary. Extracolonic manifestations and early onset of ulcerative colitis were predictive factors for developing pouchitis. Former smoking seemed to be a protective factor. CONCLUSION: The risk for pouchitis was highest during the initial six-month period. Cumulative risk leveled off after two years but was substantial (51 percent) at four years. Less than 10 percent of patients had severe, chronic pouchitis, and only two patients (1.3 percent) had their pouches removed.

Survival and cause-specific mortality in inflammatory bowel disease: a population-based cohort study.

BACKGROUND & AIMS: A population-based cohort study of 1251 subjects with Crohn's disease and 1547 subjects with ulcerative colitis, diagnosed in Stockholm between 1955 and 1984, was performed to examine the survival, changes in survival over time, and cause-specific mortality. METHODS: The cohort of patients was followed up in the National Cause-of-Death register until 1990. National mortality rates were used for comparisons. RESULTS: The observed vs. expected survival rate after 15 years was 93.7% (95% confidence interval [CI], 91.8%-95.7%) for Crohn's disease and 94.2% (95% CI, 92.4%-96.1%) for ulcerative colitis. Overall, 174 deaths occurred vs 115.42 expected (standardized mortality ratio, 1.51; 95% CI, 1.29-1.75) in Crohn's disease. In ulcerative colitis, 255 deaths occurred compared with 186.78 expected (standardized mortality ration, 1.37; 95% CI, 1.20-1.54). Inflammatory bowel disease was the major contributor to the elevated mortality rate, but mortality from colorectal cancer, asthma, and non-alcohol-related liver diseases was increased in ulcerative colitis; mortality from other gastrointestinal diseases was increased in ulcerative colitis as well as in Crohn's disease. CONCLUSIONS: Data in the present study are compatible with the hypothesis that subjects with inflammatory bowel disease have an increased mortality compared with the general population.

Crohn's disease and cancer: a population-based cohort study.

BACKGROUND/AIMS: To study the association between Crohn's disease and cancer, we performed a population-based study of 1251 subjects with Crohn's disease diagnosed in Stockholm from 1955 to 1984 and followed in both the National Cancer Register and the National Cause-of-Death Register until 1989. METHODS: For comparisons, regional cancer incidence rates in Stockholm County were used together with individually computed person-years at risk in the Crohn's disease cohort. RESULTS: Overall, 69 malignancies occurred among 67 individuals as compared with 59.80 expected malignancies (standardized morbidity ratio [SMR] = 1.15; 95% confidence interval, 0.90-1.46). An excess number of cancers of the upper gastrointestinal tract (SMR, 3.05; 95% confidence interval, 1.67-5.11) was observed, mainly because of an increased number of cancers of the small intestine (SMR, 15.64; 95% confidence interval, 4.26-40.06). An increased occurrence of urinary bladder cancer was also observed (SMR, 2.68; 95% confidence interval, 1.08-5.53). CONCLUSIONS: The occurrence of colorectal cancer was not increased.

Liver disease in ulcerative colitis: an epidemiological and follow up study in the county of Stockholm.

In an epidemiological study of the incidence of ulcerative colitis (UC) in the county of Stockholm between 1955 and 1979, 1274 patients with UC were discovered. Almost all these patients had regularly been investigated with liver function tests; 142 (11%) of them showed signs of hepatobiliary disease. A follow up study on all 142 patients with abnormal liver function and UC was made between 1989 and 1991 to evaluate the cause of the liver abnormality and to find out if the liver disease had affected the survival rates. At follow up, eight patients were reclassified as having Crohn's disease, 60 had developed normal liver function as judged from test results, while the remaining 74 still had signs of hepatobiliary disease. The most common explanation for a transient abnormality in liver function was active colitis. The temporary signs of liver injury were not associated with changes in survival rates for these patients. Infections, especially those because of hepatitis B and C virus transmitted by blood transfusions accounted for the abnormalities in liver function in 21 patients, nine of which had a chronic, but non-fatal course. Twenty nine (2.3%) of the patients developed primary sclerosing cholangitis (PSC), and 12 of them died during the study period four because of cholangiocarcinoma and eight because of hepatic failure; one patient had a transplant. The estimated median time of survival from the first presentation of evidence of a liver function, compatible with the diagnosis of PSC, to death or liver transplantation was 21 years. A comparison of survival rates in patients with UC and patients with UC and concurrent PSC showed, a significant reduction in survival in the PSC group (p<0.0001). The number of patients with UC who developed PSC remained constant during the study period. Thus, although evidence of abnormal liver function is a common finding in UC, a spontaneous return to normal levels is common. In this study, which did not have a selection bias, the median time of survival among PSC patients was far longer than previously described although development of PSC among patients with UC does significantly reduce the estimated median time of survival.

Use of oral moist snuff and inflammatory bowel disease.

We examined the association between oral moist snuff use and inflammatory bowel disease in a case-control study based on the population in Stockholm County. The relative risk (RR) associated with ever use of moist snuff was 2.1 (95% CI: 1.0-4.6) for Crohn's disease, and 2.2 (95% CI: 1.1-4.4) for ulcerative colitis. Cigarette smoking indicated a synergistic relation with moist snuff: the RR estimate of Crohn's disease was 3.7 (95% CI: 1.1-13.1) and of ulcerative colitis 3.3 (95% CI: 1.0-10.9) for snuff dippers who were also current cigarette smokers, but only 0.9 and 1.1 respectively for snuff dippers who had never smoked.

Gastric Banding for Morbid Obesity: Initial Experience with a New Adjustable Band.

A new adjustable gastric band was developed, consisting of a silicone balloon connected to a subcutaneous port In a closed system. The stoma diameter can be regulated within an extensive range (0-40 mm). The diameter is adjusted individually for each patient and weight loss can therefore be controlled and optimized. We evaluated the application of this new gastric banding procedure in terms of technical feasibility, complication rate and weight loss, and also the relationship between weight loss and pouch volume. Between January 1987 and April 1990 two preliminary studies of 18 and 24 patients respectively were carried out. In the first group there were technical problems resulting in insufficient weight loss. We therefore changed the procedure. In the second group the system thereafter worked as expected. In the second group mean preoperative weight was 132 kg, mean excess weight 60 kg, and mean BMI 45. The mean follow-up was in 21 months. At follow-up mean weight was 91 kg, mean weight loss 41 kg, and mean BMI 31. The mean postoperative stay was 6.0 days. Pouch volume and stoma diameter were followed by regular ondoscopy. There was a distinct relationship between pouch volume and weight loss-the smaller the volume the greater the weight loss.