Postoperative complications are not increased in super-super obese patients who undergo laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: It has been suggested that super-super obesity (body mass index [BMI] > or =60 kg/m2) increases the risk of complications after laparoscopic Roux-en-Y gastric bypass (LapRYGB). We hypothesized that a higher BMI does not increase risk the morbidity or mortality rate. METHODS: Complication rates for patients with a BMI > or =60 kg/m2 were compared to those for patients with a BMI <60 kg/m2 who underwent LapRYGB during the same time period. Differences between the groups were analyzed by Fisher's exact test, t-tests, and analysis of variance. RESULTS: Forty-five patients with a BMI > or =60 kg/m2 and 640 patients with a BMI <60 kg/m2 underwent LapRYGB. There were no statistically significant differences between the two groups in the complication or mortality rates. Excess weight loss was less, but actual weight lost was greater in the BMI > or =60 kg/m2 group. CONCLUSIONS: The complication and mortality rates are not increased in super-super obese patients who undergo LapRYGB. Acceptable weight loss can be achieved safely in these patients.

High failure rate after laparoscopic adjustable silicone gastric banding for treatment of morbid obesity.

OBJECTIVE: To report the results from one of the eight original U.S. centers performing laparoscopic adjustable silicone gastric banding (LASGB), a new minimally invasive surgical technique for treatment of morbid obesity. SUMMARY BACKGROUND DATA: Laparoscopic adjustable silicone gastric banding is under evaluation by the Food & Drug Administration in the United States in an initial cohort of 300 patients. METHODS: Of 37 patients undergoing laparoscopic placement of the LASGB device, successful placement occurred in 36 from March 1996 to May 1998. Patients have been followed up for up to 4 years. RESULTS: Five patients (14%) have been lost to follow-up for more than 2 years but at last available follow-up (3-18 months after surgery) had achieved only 18% (range 5-38%) excess weight loss. African American patients had poor weight loss after LASGB compared with whites. The LASGB devices were removed in 15 (41%) patients 10 days to 42 months after surgery. Four patients underwent simple removal; 11 were converted to gastric bypass. The most common reason for removal was inadequate weight loss in the presence of a functioning band. The primary reasons for removal in others were infection, leakage from the inflatable silicone ring causing inadequate weight loss, or band slippage. The patients with band slippage had concomitant poor weight loss. Bands were removed in two others as a result of symptoms related to esophageal dilatation. In 18 of 25 patients (71%) who underwent preoperative and long-term postoperative contrast evaluation, a significantly increased esophageal diameter developed; of these, 13 (72%) had prominent dysphagia, vomiting, or reflux symptoms. Of the remaining 21 patients with bands, 8 currently desire removal and conversion to gastric bypass for inadequate weight loss. Six of the remaining patients have persistent morbid obesity at least 2 years after surgery but refuse to undergo further surgery or claim to be satisfied with the results. Overall, only four patients achieved a body-mass index of less than 35 and/or at least a 50% reduction in excess weight. Thus, the overall need for band removal and conversion to GBP in this series will ultimately exceed 50%. CONCLUSIONS: The authors did not find LASGB to be an effective procedure for the surgical treatment of morbid obesity. Complications after LASGB include esophageal dilatation, band leakage, infection, erosion, and slippage. Inadequate weight loss is common, particularly in African American patients. More study is required to determine the long-term efficacy of the LASGB

Ileal pouch anal anastomosis without ileal diversion.

OBJECTIVE: To evaluate continued experience with a one-stage stapled ileoanal pouch procedure without temporary ileostomy diversion. SUMMARY BACKGROUND DATA: Most centers perform colectomy, proctectomy, and ileal pouch anal anastomoses (IPAA) with a protective ileostomy. Following a previous report, the authors performed 126 additional stapled IPAA procedures for ulcerative colitis and familial adenomatous polyposis, of which all but 2 were without an ileostomy. Outcomes in these patients question the need for temporary ileal diversion, with its complications and need for subsequent surgical closure. METHODS: Two hundred one patients underwent a stapled IPAA since May 1989, 192 as a one-stage procedure without ileostomy, and 1 with a concurrent Whipple procedure for duodenal adenocarcinoma. Patient charts were reviewed or patients were contacted by phone to evaluate their clinical status at least 1 year after their surgery. RESULTS: Among the patients who underwent the one-stage procedure, 178 had ulcerative colitis (38 fulminant), 5 had Crohn's disease (diagnosed after IPAA), 1 had indeterminate colitis, and 8 had familial adenomatous polyposis. The mean age was 38 +/- 7 (range 7--70) years; there were 98 male patients and 94 female patients. The average amount of diseased tissue between the dentate line and the anastomosis was 0.9 +/- 0.1 cm, with 35% of the anastomoses at the dentate line. With 89% follow-up at 1 year or more (mean 5.1 +/- 2.4 years) after surgery, the average 24-hour stool frequency was 7.1 +/- 3.3, of which 0.9 +/- 1.4 were at night. Daytime stool control was 95% and night-time control was 90%. Only 2.3% needed to wear a perineal pad. Average length of hospital stay was 10 +/- 0.3 days, with 1.5 +/- 0.5 days readmission for complications. Abscesses or enteric leaks occurred in 23 patients; IPAA function was excellent in 19 of these patients (2 have permanent ileostomies). In patients taking steroids, there was no significant difference in leak rate with duration of use (29 +/- 8 with vs. 22 +/- 2 months without leak) or dose (32 +/- 13 mg with vs. 35 +/- 3 mg without leak). Two (1%) patients died (myocardial infarction, mesenteric infarction). CONCLUSIONS: The triple-stapled IPAA without temporary ileal diversion has a relatively low complication rate and a low rate of small bowel obstruction, provides excellent fecal control, permits an early return to a functional life, and can be performed in morbidly obese and older patients.