Published online: 7 July 2010

LETTER FROM THE PRESIDENT

Letter of Invitation from Dr. Fobi

On behalf of the American Society for Metabolic and Bariatric Surgery, which is hosting this IFSO XV Congress, it is my honor and that of the Co-President of this Congress, Dr Henry Buchwald, to welcome you to Los Angeles/Long Beach for IFSO 2010.

The expectations for this Los Angeles/Long Beach Congress are high. Yes, it is the Fobi Congress. Yes, it is where the first international Symposium on Surgical Treatment of Obesity was hosted from 1981 through 1991. Yes, it was The International Symposium on Surgical Treatment of Obesity that brought doctors from all over the world to share their experiences in bariatric surgery. Yes, it was this International Symposium that formed the international camaraderie which was the building base for IFSO.

IFSO, since its inception in 1995 in Stockholm, has grown by leaps and bounds. The first Congress in 1996 had 265 attendees, and IFSO 2009 had 1550 attendees. We are planning for

2000 attendees in 2010. The national organizing committee has been working on the program,’ and there have been a lot of suggestions from many on what will make this Congress a must attend’ and the most talked about. The plan is to stage a high quality Congress that is affordable and meets the needs of all attendees. In addition to the posters, videos and paper sessions that will come from abstracts submitted, there will be master lectures, symposiums and roundtable panel discussions and debates. There are post-graduate courses planned on what to do, how to do it and why. There will be time for questions and interactions. Last, and most relevant, attendees will be able to earn CME credits.

The treat of this Congress is the Congress dates. It starts on a Friday and ends on a Tuesday. This allows for midweek travel for the cheaper air fares. It also permits attendees to take advantage and visit the many interesting sites in the Los Angeles/Long Beach area before and after the Congress. Los Angeles/Long Beach has representative communities from all over the world. The great restaurants reflect this diversity and allow for the adventurers and the conservatives when it comes to food choices.

Disneyland, Universal studios, Hollywood, Rodeo Drive, Sunset Boulevard, Venice Beach, Santa Monica Beach, Huntington Beach, Knoxberry Farm and various museums are within a 20- mile radius. The Los Angeles fair and the Orange county fairs will also be open. We encourage you to bring the family because there is a lot they can do.

You are as far west as you can go in mainland USA. This may be the opportunity to visit San Francisco, San Diego, Las Vegas, the Grand Canyon, Yosemite Park, Alaska, Washington State, Oregon and even Hawaii before or after the Congress.

Save the dates, and we hope to see you at IFSO 2010

From Harry Frydenberg President IFSO

It is with great pride, and a little nostalgia, that I invite you to attend the IFSO XV World Congress in Long Beach, Los Angeles, California, 3-7 September 2010. As you can see in Dr. Mal Fobi’s introduction, there has been a longstanding association between California and Obesity Surgery.

With the passing years, the field of Bariatric, and now Metabolic, Surgery has grown exponentially to the point of not only acceptance by our surgical colleagues and the public at large, but leads in the area of upper gastrointestinal surgery, with evidence of long- term reduction in mortality, improvement and, in so many cases, resolution of significant life-threatening comorbidities.

It is at our Scientific meetings that we all get an opportunity to present and hear the results of our endeavours, be they in the field of scientific research, clinical practice or new developments in technology, as seen recently by the use of Robotics in Bariatric Centres. IFSO brings together Surgeons and Allied Health Professionals from around the globe, each geographical area represented by a regional Chapter and each Chapter catering to the differences in demographics and the differences in the nature of metabolic disorders associated within these diverse populations.

So take this opportunity to enjoy intellectual stimulation and peer group camaraderie, together with an active social program, all in a beautiful environment and a warm climate.

Looking forward to greeting you all at IFSO 2010. Warmest regards, Harry Frydenberg President IFSO

QUICK REFERENCE

LOCATION SOCIAL EVENTS Long Beach Convention Center Saturday September 4 300 East Ocean Boulevard ASMBS FOUNDATION WALK FROM OBESITY Long Beach, CA 90802-4825 7:00 am – 9:00 am 562.436.3636 Sunday, September 5 CONTACT OPENING CEREMONY AND RECEPTION ASMBS 6:30 pm – 9:30 pm 100 SW 75th Street, Suite 201 Gainesville, FL 32607 USA Monday, September 6 P: 352.331.4900 F: 352.331.4975 CLOSING GALA www.ifso2010.org 7:00 pm – 12:00 am

IFSO EXECUTIVE 2009-2010

President Harry Frydenberg (Australia) President-Elect Karl Miller (Austria) Immediate Past President MAL Fobi (USA) Senior Past President Rafael Alvarez-Cordero (Mexico) Secretary/Treasurer Luigi Angrisani (Italy) Chair, Board of Trustees Martin Fried (Czech Republic) IFSO Honorary Presidents Nicola Scopinaro (Italy) John Baker (USA) ASMBS President IFSO 2010 Co-Presidents MAL Fobi (USA) Henry Buchwald (USA) IFSO Historian George Cowan ((USA) ASMBS Representative Kelvin Higa (USA) European Chapter Representative Antonio Jose Torres (Spain) Latin-American Chapter Representative Luis Ibanez (Chile) Asia-Pacific Chapter Representative Sanjay Borude (India) Executive Director OBESITY SURGERY Journal Co-Editors Nicola Scopinaro (Italy) Henry Buchwald (USA) Secretariat: Ngwebifor Fobi, Khagen Consulting (USA)

LOCAL ORGANIZING COMMITTEE

President of the Congress Mathias Fobi Co-President of the Congress Henry Buchwald Co-Chair, Scientific Committee Eric DeMaria Co-Chair, Scientific Committee Phillip Schauer Co-Chair, Scientific Committee Scott Shikora Co-Chair, Health Integrated Session William Gourash Co-Chair, Latin America Post Graduate Course Luis Ibanez

CONGRESS SECRETARIAT

ASMBS Secretariat Patricia Watson Kristie Kaufman

GENERAL INFORMATION

CONGRESS VENUE The 15th World Congress of IFSO 2010 will be held September 3-7, 2010, at the Long Beach Convention and Entertainment Center (300 East Ocean Boulevard, Long Beach, California, USA)

LANGUAGE The official language of the congress will be English, with translation available.

LETTER OF INVITATION Upon request, the Organizing Committee will send an invitation to participate in the congress. Such invitation does not imply any commitment on the part of the organizers to provide financial support.

PASSPORTS AND VISA If you are traveling from outside the United States, please visit the U.S. Department of Homeland Security (http://www.dhs.gov) to apply for your travel authorization. *Please submit your own application and do not apply through a third party site. If your application is not correct you may be denied entry by U.S. Customs.

CLIMATE AND CLOTHING The weather in Long Beach in summer is warm and sunny with high temperatures ranging from 70 to 80 degrees Fahrenheit (21˚C) and low temperatures averaging 55 degrees Fahrenheit (13˚C). Jackets and sweaters are recommended, particularly in the evenings.

CURRENCY The national monetary unit in the United States is the U.S. Dollar. Exchange facilities are available at the airport, major hotels, and exchange agencies.

ELECTRICITY Electricity in United States/USA is 120 volts, alternating at 60 cycles per second. If you travel to the United States of America/USA with a device that does not accept 120 vVolts at 60 Hertz, you will need a voltage converter. Please see our web site for important information.

LIABILITY IFSO2010 Management hereby assumes no liability for any claims, personal injury or damage that may arise out of the 15th World Congress of the IFSO.

EXHIBIT AREA The Commercial Exhibition will take place at the Long Beach Convention Center – Hall A. Interested companies should contact the Congress Secretariat: ASMBS Secretariat: [email protected]

LODGING HYATT REGENCY LONG BEACH – Conference Hotel Headquarters 200 South Pine Avenue, Long Beach, CA 90802 1-800-633-7313 (Refer to code ASMBS) Room Rate: $159.00

THE WESTIN LONG BEACH HOTEL 333 East Ocean Blvd, Long Beach, CA 90802 1-800-937-8461 Room Rate: $179.00

RENAISSANCE LONG BEACH HOTEL 111 East Ocean Blvd, Long Beach, CA 90802 Phone: 1-800-627-7468 (Refer to code ASMASA) Room Rate: $179.00

LONG BEACH There is always something special in Long Beach. Discover the city's best-known attractions, which range from a historic ocean liner to a state-of-the-art aquarium. Then check out the city's other rare and unique treasures, from the Museum of Latin American Art to the Tallships in Rainbow Harbor. You will find a wealth of shopping experiences from one-of-a-kind boutiques to popular Southern California shops

ABOUT LONG BEACH Long Beach, California is a beautiful city that includes one of the nation's busiest ports and largest marina docking everything from the tiny sabot sailboat invented here, to the historic Queen Mary Ship and huge freighters from around the world!

PLACES OF INTEREST

Aquarium of the Pacific 100 Aquarium Way, Long Beach. 562.590.3100. Its 17 major tanks and 30 smaller tanks can be taken in an afternoon, and along the way there are some amazing specimen to be found in an ocean of more than 12,000 species. There is an iridescent jellyfish exhibit, a rare dragonfish that has to be seen to believe, and an array of toothy mammals in the Shark Lagoon, where one can get up close and personal with the feared predators.

The Queen Mary The hotel’s 314 original staterooms span three decks and include eight full suites. Each cabin is uniquely appointed, and embellishments vary to include rich wood paneling; Art Deco built-ins; original artwork; and, portholes for outside cabins. Her active career finished in the service of passenger transport from 1947 through 1967. The Queen Mary officially became part of Long Beach’s waterway focal points in December 1967.

HOLLYWOOD

Grauman’s Chinese Theatre 6925 Hollywood Blvd., LA. This theatre has been a cornerstone of Hollywood for over 75 years. An historic cultural landmark, the Chinese Theatre in Los Angeles is visited by more than four million visitors from all over the world every year and is the most sought-after studio in Hollywood for studio premieres. The Hollywood Walk of Fame runs right in front of the theatre.

The Walk of Fame 6801 Hollywood Blvd., LA. The Walk of Fame, located in Hollywood, is a tribute to the history of the Hollywood-based entertainment industry. One of Hollywood’s most visited landmarks, it honors stars that have made significant contributions in categories such as radio, television, motion pictures, recording and live performance.

The Hollywood Sign Stands over four stories high with each letter running 50 feet from its base. Created and erected by Harry Chandler in 1923, the sign originally read HOLLYWOODLAND and was an invitation to all up and coming star seekers coming to “The Land of Dreams” to search for their big shot in the entertainment industry. After the sign was neglected throughout the Great Depression, the Hollywood Chamber of Commerce stepped in to repair it and remove the last four letters, creating the iconic HOLLYWOOD sign that visitors know today.

Page Museum at the La Brea Tar Pits 5801 Wilshire Blvd., LA. 323.934.7243. Settled quietly beside the stretch of Wilshire Boulevard known as the Miracle Mile, the La Brea Tar Pits are a sticky reminder of LA’s extensive prehistory as well its role as a large producer of petroleum products, such as asphalt. The park is home to several pits of liquid asphalt bubbling with methane. The Page Museum at the La Brea Tar Pits is home to the most extensive collection of ice-age fossils in the world. Visitors can watch both their excavation and classification through observation windows. Kids will find the recreation of a Pleistocene forest in the center of the museum fun and exciting.

Getty Center 1200 Getty Center Dr., LA. 310.440.7300 This Los Angeles museum received most of its early publicity because of Richard Meier’s stone and glass design. Once in the womb of this creative mothership, the peaceful, airy exhibition spaces, and extensive collection make for a breathtaking SoCal afternoon. MEETING OUTLINE *This Preliminary Outline is tentative and subject to change.

Friday, September 3 Post Graduate Courses 10:15 am – 11:30 am 8:00 am – 5:30 pm SYMPOSIUM: GASTRIC BANDING AND METABOLIC SURGERY GASTROPLASTY

8:00 am – 5:00 pm SLEEVE GASTRECTOMY 10:30 am – 12:00 pm SESSION ONE – METABOLIC SURGERY I 8:00 am – 12:00 pm SINGLE-INCISION LAPAROSCOPIC SURGERY, 10:30 am – 12:00 pm FLEXIBLE ENDOSCOPY AND EMERGING SESSION TWO: GENERAL INTEREST ENDOLUMINAL PROCEDURES

1:30 pm – 3:00 pm 1:00 pm – 3:00 pm SINGLE-INCISION LAPAROSCOPIC SESSION THREE: SLEEVE SESSION I BARIATRIC SURGERY LAB 1:30 pm – 3:00 pm 3:30 pm – 5:00 pm SESSION FOUR: MALABSORPTION AND THERAPEUTIC ENDOSCOPY LAB GENERAL INTEREST

Saturday, September 4 1:30 pm – 3:00 pm Post Graduate Courses BARIATRIC BEHAVIOR HEALTH ESSENTIALS: 7:00 am – 9:00 am PSYCHOSOCIAL ASSESSMENT AND ASMBS FOUNDATION INTERVENTIONS BEFORE AND AFTER WALK FROM OBESITY WEIGHT LOSS SURGERY

10:00 am – 5:30 pm 3:45 pm – 5:20 pm INNOVATIONS IN ENDOLUMNAL SESSION FIVE: COMPLICATIONS I 10:00 am – 12:00 pm QUALITY IMPROVEMENT, COE AND BEYOND 3:45 pm – 5:25 pm SESSION SIX: GASTRIC BYPASS 10:00 am – 5:30 pm LATIN AMERICA COURSE 3:45 pm – 5:30 pm

VIDEO SESSION 10:00 am – 5:30 am INTEGRATED MULTIDISCIPLINARY APPROACH/TEAM IN BARIATRIC SURGERY: Monday, September 6 “MORE THAN THE SUM OF ITS MEMBERS” Oral Session 7:30 am – 6:30 pm 1:30 pm – 5:30 pm RISK MANAGEMENT AND LIABILITIES 7:30 am – 9:45 am

SYMPOSIUM: METABOLIC SURGERY Sunday, September 5 Oral Session 7:30 am – 6:30 pm 10:30 am – 12:00 pm SYMPOSIUM: BPD & BPD WITH SWITCH 7:30 am – 9:30 am SYMPOSIUM: GASTRIC BYPASS 10:30 am – 12:00 pm

SESSION SEVEN: COMPLICATIONS II

10:30 am – 12:00 pm VIDEO SESSION

10:30 am – 12:00 pm INTEGRATED HEALTH

1:30 pm - 3:00 pm SYMPOSIUM: SLEEVE GASTRECTOMY

1:30 pm – 3:00 pm SESSION EIGHT: GENERAL INTEREST/COMPLICATION OR REVISIONS

3:45 pm – 5:00 pm INVITED PANEL: BMI AND STANDARD OF CARE

Tuesday, September 7 Oral Session 7:45 am – 6:30 pm

7:45 am – 9:00 am SYMPOSIUM: ROUND UP

8:00 am – 9:30 am SESSION NINE: REVISIONS

8:00 am – 9:30 am SESSION TEN: GASTRIC BANDING

10:30 am – 12:30 pm SESSION ELEVEN: METABOLIC SURGERY II

10:30 pm – 12:30 pm SESSION TWELVE: SLEEVE II

*Faculty and talks are subject to change.

IFSO2010 REGISTRATION FORM

Please PRINT and fax completed form to 001.352.331.4975 or mail with payment to ASMBS, 100 SW 75th Street, Suite 201, Gainesville, FL 32607 USA. For your convenience, you can register online at www.IFSO2010.com. Only the person registered will be allowed to pick up meeting materials. Please have picture identi cation available. If faxing, please be sure to fax both pages of the registration form.

CONTACT AND MAILING INFORMATION (exactly as it should appear in IFSO2010 Publications)

Last Name First Name Middle Initial Credentials (MD, RN, Etc.)

Institution

Address

City State Zip Country

Telephone Fax Email

Institution Web Address Check here if you would prefer NOT to receive email communications from exhibitors at the 15th World Congress.

Please check one:

Surgeon Psychologist Dietician Medical Student

Physician Nurse Physician’s Assistant Other ______

PAYMENT INFORMATION Total Registration Fees (Registration plus social event tickets) $

Bill Credit Card for: $ Name on Card:

Check (Made payable to IFSO) Funds Transfer: Bank of America Bank Account # 003446334528 ABA # 026009593 SWIFT Code: BOFAUS3N

AMEX VIsa MasterCard # Exp

Printed Name on Card:

Signature:

Billing Address (If dierent from mailing address)

ADA accommodations will be made in accordance with the law. If you require ADA accommodations, please indicate what your needs are at the time of registration. We cannot ensure the availability of appropriate accommodations without prior noti cation. IFSO2010 REGISTRATION FORM

DAY 1 - FRIDAY, SEPTEMBER 3, 2010 Surgeon Allied Health Members Non Members Members Non Members 8AM - 5PM Early Late Early Late Early Late Early Late

Restrictive Bariatric Surgery Course ___$175 ___$200 ___$275 ___$300 Sleeve Gastrectomy ___$250 ___$300 ___$350 ___$400

Metabolic Surgery ___$250 ___$300 ___$350 ___$400 ___$175 ___$200 ___$275 ___$300

Sils Course and Lab

Didactic Only ___$150 ___$200 ___$250 ___$300

Didactic with Both Labs ___$750 ___$800 ___$850 ___$900

Lab A: Single Incision (Limited Lab) ___$400 ___$450 ___$500 ___$550

Lab B: Theraputic Endoscopy (Limited Lab) ___$400 ___$450 ___$500 ___$550 DAY 2 - SATURDAY, SEPTEMBER 4, 2010 Surgeon Allied Health Members Non Members Members Non Members 10AM - 5:30PM Early Late Early Late Early Late Early Late

Integrated Multidisciplinary Approach in Bariatric Surgery ___$250 ___$300 ___$350 ___$400 ___$175 ___$200 ___$275 ___$300

Quality Improvement, COE & Beyond ___$250 ___$300 ___$350 ___$400 ___$175 ___$200 ___$275 ___$300

Innovative Procedures ___$250 ___$300 ___$350 ___$400 ___$175 ___$200 ___$275 ___$300

Latin American Course ___$250 ___$300 ___$350 ___$400 ___$175 ___$200 ___$275 ___$300

DAYS 3-5 - SUNDAY - TUESDAY, SEPTEMBER 5-7

SCIENTIFIC PROGRAM

Students / Residents Surgeon Allied Health Members Non Members Members Non Members Members Non Members Early Late Early Late Early Late Early Late Early Late Early Late

___$300 ___$350 ___$350 ___$400 ___$500 ___$550 ___$550 ___$600 ___$300. ___$350 ___$400 ___$450

Includes one Opening Ceremony ticket and one Closing Gala ticket. Include complimentary tickets? ____Yes ____No

ACCOMPANYING PERSON FEE

Provides for Exhibit Hall Entry, Lunch on Saturday/Sunday/Monday and One (1) Opening Ceremony and Reception Ticket only ____$250

SOCIAL EVENTS

Opening Ceremony and Reception Terrace Theater at the Convention Center Saturday, September 4, 2010 6:30pm - 9:30pm ___$85.00

Closing Gala Hyatt Regency Hotel Monday, September 6, 2010 7pm - 12am ___$45.00 Pre-surgery ghrelin was significantly lower in obese and diabetics O-001 Bariatric Surgery Improves Glucose Control In Obese than lean (p<0.05), but there were no changes in obese or diabetic Patients With Type 1 Diabetes post-surgery. Conclusion: The satiety following RYGB may be due to the increase PRESENTER: David Spector (Tufts Medical Center) in PYY, but not due to changes in either Ghrelin or leptin.

1 1 Co-Authors: Perry, Zvi ; Shikora, Scott O-003 C-Peptide Predicts The Remission Of Type Ii Diabetes (T2dm) After Sleeve Gastrectomy 1. Surgery, Tufts Medical Center, Boston, MA, United States. PRESENTER: Yen Su (Min-Sheng General Hospital) Background: The prevalence of diabetes is growing worldwide for both Type 1 and Type 2 Diabetes Mellitus (T1DM, T2DM). The association between obesity and T2DM has been well demonstrated, Co-Authors: Su, Yen H.1; Lee, Wei J.1; Lee, Yi-Chih 1; Chen, Jung- with gastric bypass achieving cure rates above 80%. T1DM patients Chien1; Ser, Kong-Han 1; Chen, Shu-Chu 1 are usually leaner, but similar to the general rise in obesity, reports are revealing these patients to be more than 35% overweight at onset of disease. Furthermore, intensive insulin treatment causes even more 1. General Surgery department, Min-sheng General hospital, Taipei, Taiwan. weight gain. It is unclear what role bariatric surgery has with obese T1DM patients; only two case reports have been published. Methods: Retrospective analysis of prospectively collected bariatric Background: This trial assessed the clinical significance of C-peptide surgery patients with T1DM; 5 patients underwent gastric bypass, in bariatric surgery and T2DM remission after laparoscopic sleeve and 2 gastric banding. gastrectomy (LSG). Results: The mean postoperative follow-up was 45.4 months. Only one patient suffered a complication (DVT). The preoperative and Methods: The study was a prospectively controlled clinical study. postoperative results for the mean BMI was 40.05 vs. 31.16 From 2003 to 2008, of 413 consecutive bariatric patients with at least (p=0.018); the mean glucose level was 239 vs. 150 mg/dl (p=0.028); 1 year‟s follow-up were examined (81.8% received laparoscopic the mean HbA1c was 8.51 vs. 7.34 (p=0.046); and the mean daily gastric bypass (LGB), 18.2% (LSG). Among them, 88 patients had insulin dosage was 54.7 vs. 34.6 units (p=0.028). The effects were T2DM. more robust for the gastric bypass patients. Results: The mean C-peptide before surgery was 5.0 + 7.1 ng/ml. Conclusion: Bariatric surgery is effective and safe for obese T1DM Among all, 169 (40.9 %) had elevated C-peptide (> 4 ng/ml) and 3 patients. The results demonstrate that patients after bariatric surgery (0.7%) had low C-peptide (<0.9 ng/ml). Multivariate analysis have better control over glucose levels, require less daily insulin confirmed insulin resistance represented by the HOMA index is the doses, and have lower HbA1c. These changes are likely the result of independent predictor for the elevation of C-peptide. Mean C-peptide a combination of factors including lowered caloric intake, lowered decreased to 1.6 + 0.9 ng/ml (68%) one year later. LGB lost BMI (insulin resistance), and elevated Incretin effect. Possibly, significantly more weight (38.7 vs. 27.8 kg, p<0.001) and achieved a T1DM should be considered a comorbidity strengthening the lower BMI, C-peptide, glucose and blood lipid than LSG. Overall, indication for bariatric surgery. the T2DM remission rate was 77.2% (68/88) and higher in LGB than in LSG [59/68(86.7%) vs.9/20(45.0%), p=0.000]. In LSG, the O-002 The Enigma of Satiety following Gastric Bypass remission rates for those with pre-operative C-peptide < 3, 3-6 and > 6 ng/ml were 1/7(14.3%), 6/11(54.5%) and 2/2(100%) separately (p<0.05). PRESENTER: John Pender (The Brody School of Medicine, East Conclusion: Bariatric surgery significant reduced C-peptide and Carolina University) achieved a T2DM remission rate of 77.2%. LSG is recommended for T2DM patients with elevated C-peptide and C-peptide > 3 ng/ml is the most important predictor for a successful treatment of T2DM. Co-Authors: Chapman, William H.1; Koury, Michael K.1; Reed, Melissa A.1; Reed, Christopher M.1; Jernigan, Kelly E.1; Tapscott, Edward B.1; Dohm, Lynis G.1; Pories, Walter J.1 O-004 Gastric Remnant Tube Placement During RYGB In A Rat Model To Achieve Selective Gut Stimulation 1. Surgery, The Brody School of Medicine, East Carolina University, Greenville, NC, United States. Presenter: Kibwe Weaver (Cleveland Clinic, USA)

Background: Our finding that Roux-en-Y Gastric Bypass (RYGB) Co-Authors: 1; Sabagh, Fahed1; Dan, Olivia1; Huang, Hazel2; produces rapid, full and durable remission of type 2 diabetes in 83% Kashyap, Sangeeta1; Schauer, Philip1; Kirwan, John2; Brethauer, of severely obese patients (Ann Surg 222(3):339-352) led us to Stacy1 explore the role of leptin, peptide YY (PYY), and ghrelin on satiety following a gastric bypass. Methods: Leptin, ghrelin, and PYY were measured in the fasting state 1. Bariatric and Metabolic Institute, Cleveland Clinic , Cleveland, and after a mixed meal challenge (150 kcal), prior to surgery and 1- OH, United States. week and 3 months post-op in morbidly obese non-diabetics (obese) 2. Department of Pathobiology, Cleveland Clinic , Cleveland, OH, and morbidly obese diabetic (diabetic) patients (BMI>35). Lean United States. subjects were used for a control comparison (BMI<25). PYY was expressed as area under the curve (AUC) of the meal test. Background: The mechanisms by which Roux-en-Y gastric bypass Results: Leptin was drastically reduced in both obese and diabetics (RYGB) surgery ameliorate Type 2 diabetes are not fully understood. post surgery (p<0.01). PYY was significantly increased 1-week Exclusion of nutrient flow through the duodenum has been proposed following surgery in both obese and diabetics (p<0.01). Diabetics as a potential mechanism that results in improvement of glucose maintained elevated levels of PYY 3-months post-surgery (p<0.01). metabolism prior to weight loss. This pilot study was intended to establish a rodent model that allows selective stimulation of the Table 1. proximal bowel after RYGB. Methods: After obtaining approval from the animal use committee, Fasting six rats underwent RYGB according to our established techniques. Follow Fasting BMI BMI Glycaemi Cured All six also had a gastrostomy tube placed in the gastric remnant at -up: Glycaemia (Kg/m2)Pr (Kg/m2)Pos a patient the time of RYGB. A 4 mm silastic tube was placed in the excluded 3 (mg/dl)Pos e-op t-op (mg/dl)Pr s (%) stomach and tunneled subcutaneously to the mid-scapular region. The months t-op e-op tubes were flushed daily with water to maintain patency. All subjects underwent baseline oral glucose tolerance testing (OGTT) GROU preoperatively and oral and gastrostomy tube glucose tolerance P A 45.1±6.9 36.3±4.6 238±56.8 109±18.6 7 (35) testing (GT-GTT) 14 and 28 days after surgery. (n=20) Results: All 6 rats survived to the endpoint of the study and glucose GROU 51 tolerance testing was completed for all rats. Using area under the P B 46.3±12 37.2±6.7 140±31 97.2±22.3 (100) curve analysis (AUC) there was significant improvement in oral (n=51) glucose tolerance 14 and 28 days after RYGB (P<0.001) compared to baseline. The AUC was significantly increased at 14 and 28 days with GT-GTT compared to the decrease observed in the OGTT group (P=0.001). O-006 Duodenal Switch in Children Conclusion: Placement of a gastrostomy tube into the gastric remnant at the time of RYGB in a rat model is feasible and may be a valuable tool to evaluate the metabolic effects of selective gut stimulation. In PRESENTER: Simon Marceau (Laval Hospital) this pilot study, delivery of glucose into the duodenum via the G tube resulted in worsening glucose tolerance compared to the oral route. This model provides the basis for further mechanistic studies Co-authors: Biron, Simon1; Biertho, Laurent1; Lescelleur, Odette1; regarding the resolution of Type 2 diabetes after RYGB surgery. Lebel, Stefane1; Hould, Frederic-Simon1; Marceau, Picard1

O-005 T2dm And Sleeve Gastrectomy : Diabetes Duration As 1. General Surgery, Laval Hospital, Québec, QC, Canada. Prognostic Factor Of Cure. Background: Morbid obesity in children as in adult is a progressive PRESENTER: Nicola Basso (Policlinico Umberto I University damaging disease for which surgery has been proven to be the most Sapienza) efficient treatment. We wanted to report our experience with duodenal switch (DS), our bariatric procedure of choice. Methods: In the last 15 years, 13 consecutive children had a DS and Co-Authors: Casella, Giovanni1; Rizzello, Mario1; Abbatini, have been followed since. Francesca1; Alessandri, Giorgio1; Soricelli, Emanuele1 These children were recently interviewed and had blood drawn for analysis. Nutritional status and metabolic condition were compared with pre-operative condition. Three children with Prader-Willi 1. Surgical Medical Department of Digestive Diseases, Policlinico Syndrome were excluded. Umberto I University Sapienza, Rome, Italy. Results: The follow-up was 100% (n=10). There was no death, no postoperative complication. After a mean follow-up of 10.6±5.3 Background: To evaluate the efficacy of LSG on glucose years, body mass index has decreased from 55.9±14.0 to 28.8±3.7 homeostasis in morbidly obese subjects with Type 2 Diabetes kg/m2 . There was no failure. All co morbidities were resolved but Mellitus (T2DM) and to elucidate the role of disease duration on one case of improved asthma. Two patients have been re-operated: resolution. one for intestinal obstruction and the other for a peptic ulcer. Methods: From October 2002 to December 2009, 300 patients Metabolically, the mean cholesterol level 4.6±0.9 and fasting glucose underwent LSG for morbid obesity. Seventy-one patients presented level 5.3±0.3 significantly decreased to 3.2±0.9 (p<0.01) and 4.6±0.5 T2DM; 20 of them had a diabetes duration >10 years (F/M 14/6, (p<0.004) respectively. There was no deficiency found for any of the mean age 53±5.3, mean pre-operative BMI 45.1±6.7 Kg/m2): nutritional markers studied. Among our cohort, five became mothers GROUP A; 51 patients had a diabetes duration <10 years (F/M giving birth to a total of eleven children. They are all in good health 40/11, mean age 49.4±7, mean pre-operative BMI 46.3±11.7 Kg/m2): and the mean BMI percentile for these children is 49±32 % (n=10). GROUP B. The cut-off of ten years is the arithmetic mean of disease Conclusion: We conclude that DS in morbidly obese children allows duration in all diabetic patients. sustainable weight loss with significant improvements of comorbid Results: In GROUP A 12 patients were on oral hypoglycaemic agents conditions and is associated with a low and very acceptable surgical and 8 on insulin therapy. In GROUP B 47 patients were treated with and metabolic risk. oral hypoglycaemic and 5 on insulin therapy. At 3 months after LSG 58/71 patients (81,7%) discontinued the O-007 Four-Year Results After BPD-DS In Patients With antidiabetic therapy. The 3 months post-operative data for each group Insulin-Dependent Type 2 Diabetes Mellitus. are reported in table 1. However, in the “non cured” group the patients were more sensitive PRESENTER: Michael Frenken (St. Josef to lower doses of antidiabetic drugs. Significantly reduced dosages Krankenhaus) were able to obtain normal fasting glycaemia levels. The cut-off of ten years is the arithmetic mean of disease duration in all diabetic Co-authors: Cho, Eun-Young1 patients. Conclusion: The LSG is effective in the treatment of obese patients 1. St. Josef Krankenhaus, Monheim, Germany. with T2DM. Diabetes duration seem to be paramount prognostic factor, being 10 years a cut-off between a 100% cure and a less Background: To evaluate 4-year results on diabetes after resolution. biliopancreatic diversion with duodenal switch (BPD-DS) in patients with insulin-dependent type 2 diabetes. Methods: We conducted a prospective study in 68 consecutive Diastolic Blood pressure (mmHg) 84.6±7.7 80.9±11.7 0.128 patients undergoing BPD-DS for insulin-dependent type 2 diabetes mellitus (mean age 50 years, range 26-68, 41 female). The operation Total cholesterol (mg/dL) 198±34.3 154±31.9 <0.001 was performed as an open procedure. The effects of the surgery on HDL-C (mg/dL) 43.3±8.8 40.8±9.1 0.09 diabetes and its treatment within 4 years after surgery were assessed. Results: Mean preoperative diabetes treatment was 10.4 years, mean LDL- C (mg/dL) 122.5±28 90.1±25.6 <0.001 insulin-dependence 6.4 years with a mean daily use of 127 units of Triglycerides (mg/dL) 161.2±73.6 115.3±46.3 0.001 insulin before operation. After BPD-DS, insulin treatment was ceased in 49 patients (75%) within 2 weeks after operation and in 63 patients Fasting glucose (mg/dL) 102.3±26.1 92.9±16.6 0.044 (93%) within 1 year. After 1 year and up to 4 years, 5 patients Metabolic syndrome (n,%) 24(63.2) 13(46.4) 0.012 continuously required small amounts of insulin to keep blood sugar below 200 mg/dl: one patient with LADA and 4 patients with insulin secretion failure (C-peptide <1 ng/ml). These latter 4 patients had O-009 Metabolic surgery in non obese type 2 diabetic patients used insulin preoperatively for 13, 15, 22 and 25 years. However, 15 of 19 patients (79%) with insulin-dependence of 10 and more years PRESENTER: Marcos Berry (Clinica Las Condes) had complete remission of diabetes. The mean HbA1c level preoperatively and 3 months, 6 months, 12 months, 2 years, 3 years Background: Bariatric surgical procedures resolve diabetes within and 4 years after surgery was 9.5, 6.6, 5.7, 5.3, 5.4, 5.5 and 5.4%, days to weeks after discharge. Based on Rubino‟s research on respectively, including the 5 patients with insulin treatment. animals, Laparoscopic Duodeno Jejunal Bypass (LDJB) has been Conclusion: BPD-DS causes complete remission of diabetes in 93% proposed as treatment for non obese type 2 diabetic patients. The of patients with insulin-dependent type 2 diabetes mellitus. But only objective of this work is to evaluate the LDJB as surgical option in patients with insulin-dependence of more than 10 years seem to be this specific group of patients. vulnerable to failure of complete control of diabetes. Methods: Methods: Prospective case series of 19 patients operated by our group from March 2008 to August 2009. The first 8 patients O-008 One-Year Study Of Weight Loss And Metabolic Syndrome underwent the following procedure: transection of duodenun 2 cm Improvement Resulting From Use Of The Endoscopic Duodenal- distal to the pylorus, duodeno jejunostomy with bilipancreatic limb of Jejunal Bypass Liner 150 cm and alimentary limb of 100. The following 11 patients were added a sleeve gastrectomy. PRESENTER: Alex Escalona (Pontificia Universidad Católica de Results: Results: 18 male and 1 female patient. Mean age: 45 yo (34- Chile) 62). Mean preoperative glucose level was 176 mgr% and mean post operative level was 147 mgr% in LDJB and 174 mgr% and 122 Co-Authors: Becerra, Pablo1; Gabrielli, Mauricio1; Turiel, Dannae1; mgr% (p= 0,06) respectively in the sleeve added group, being non Awruch, Diego1; Pimentel, Fernando1; Sharp, Allan1; Ibanez, Luis1; significant. The mean preop HBA1c level was 9,2% in the LDJB Galvao, Manoel3; Bambs, Claudia2 group and 9,42% (p= 0,9) in the sleeve added group. The mean postop HbA1c level in the LDJB was 8,5% vs 6,3% in the sleeve 1. Digestive Surgery, Pontificia Universidad Católica de Chile, aded group, being this difference significant (p= 0,05). Four patients Santiago, Chile. presented complications in the LDJB: 1 anatomotic leek resolved and 2. Public Health, Pontificia Universidad Católica de Chile, Santiago, 3 gastroparesis. No complication related to sleeve added group. No Chile. mortality reported. 3. Gastro-Obeso Center, Sao Paulo, Brazil. Conclusion: Conclusion: Our series is small and we added a variation to Rubino‟s technique due to gastroparesis encoutered With this variation we report better metabolic control in our series and less Background: The endoscopic, duodenal-jejunal bypass liner (DJBL, complications, though our series is still small to draw straight EndoBarrier™, GI Dynamics, Inc, Lexington, MA) has been shown conclusions. to promote weight loss and improve type 2 diabetes for up to 6 months in subjects who are morbidly obese. This ongoing study was designed to evaluate weight loss and co-morbidity changes in obese O-010 Improvement And Remission In Type 2 Diabetes Mellitus subjects for up to 12 months of implant duration. We report here the After Laparoscopic Vertical Sleeve Gastrectomy In Obese results at 9 months of follow-up. Patients Methods: The DJBL was endoscopically implanted in 39 obese subjects in one center (Santiago, Chile). Mean age and BMI were PRESENTER: Juan Contreras (Clinica Santa Maria) 34.8±10 years and 43.8±5.8 kg/m2, respectively. Results: There were no procedure related complications. Mean implant delivery time was 23 + 11 minutes. There were 10 early Co-Authors: Villao, Diva1; Bravo, Jorge1; Court, Ismael A.1 endoscopic removals due to device movement (3), liner obstruction (3), abdominal pain (2), acute cholecystitis (1) and patient request (1). The mean %EBWL at 3, 6 and 9 months was 22.0%, 29.4% and 1. Surgery and Bariatric, Clinica Santa Maria, Santiago, D.F., Chile. 35.9%, respectively. A significant improvement in most clinical and metabolic variables was observed (Table). Background: The results regarding remission or improvement of type Conclusion: The DJBL induces continued weight loss during 9 2 diabetes mellitus (DM2) after Laparoscopic vertical sleeve months of implantation and significant improvements in metabolic gastrectomy (VSG) have been encouraging and even comparable to syndrome. those observed in other larger techniques such as bypass surgery. Methods: A uncontrolled prospective study of patients with DM2 undergoing VSG from November 2005 to May 2009 by the same Baseline 9 months p-value team and under the same standards of surgical technique, Waist circumference (cm) 116.6±12 97.3±12.2 <0.001 preoperative evaluation and postoperative management. We evaluated the results of DM2 in terms of resolution, improvement or Systolic Blood pressure (mmHg) 133.1±13.9 126.0±143 0.016 indifference, as clinical and laboratory parameters. Results: From 300 patient underwent to VSG, 7.7% have T2DM. Reported 30% male and 70% women. Average age: 50.6 ± 8.4 years, preoperative weight: 118.3 ± 23.2 kg, BMI: 45,2 ± 8.6 kg/m2, fasting blood glucose: 143.4 ± 31.1 mg / dl and glycosylated hemoglobin: 7.4 ± 1.5%. At follow-up at 1, 6 and 12 months was observed a loss of excess weight of 26.7 ± 14.4; 50 ± 17 and 64 ± 18% respectively. The evolution of the average fasting glucose at 1, 6 and 12 months were: 103.5 ± 16mg/dl; 99.1 ± 14.2 mg / dl and 105.7 ± 22.8 mg / dl respectively (p < 0.01) and glycated hemoglobin: 5.7 ± 0.8%, 5.8 ± 1%, 5.8 ± 0.4% (p <0.01) respectively. At follow-up year 60% had remission and 30% improvement in DM2. Conclusion: The VSG is an effective technique for control of DM2 in obese patients, revealing a significant metabolic control demonstrated in both clinical and laboratory parameters, maintaining the same year O-012 Case Matched Outcomes of Routine Medical Management, follow up Adjustable Gastric Banding and Duodenal Switch Versus Roux- en-Y Gastric Bypass for Type 2 Diabetes O-011 Potential Role Of Bilio-Pancreatic Limb On Intestinal Sweetness Sensing Following Gastric Bypass Surgery Presenter: Sayeed Ikramuddin, MD,

Co-Authors: Daniel B. Leslie, MD, Federico Serrot, MD, Bridget Presenter: Kamran Abolmaali (Brigham & Women's Hospital) Slusarek, RN, John P. Bantle, MD, Therese Swan, Henry Buchwald, MD, PhD

Co-Authors: Rhoads, David B.2; Tavakkolizadeh, Ali1 University of Minnesota, Minneapolis, MN

1. Surgery, Brigham & Women's Hospital, Boston, MA, United Objectives No controlled data exists comparing the efficacy of States. various bariatric operations on type 2 diabetes (T2DM). We 2. Pediatric Endocrine, Massachusetts General Hospital, Boston, MA, performed a matched case control study of subjects with T2DM who United States. are severely obese undergoing routine medical management (RMM), laparoscopic adjustable gastric banding (LAGB), and duodenal switch (DS) to patients undergoing Roux-en-Y gastric bypass Background: The mechanisms underlying the metabolic benefits of (RYGB) in order to determine relative outcomes. Roux-en-Y gastric bypass (RYGB) are poorly understood. We have Methods: Subjects were matched by body mass index (BMI), gender, previously shown that proximal intestine is capable of detecting composite diabetes medication score (0-5), hemoglobin A1c (HbA1c) luminal sugars through activation of sweet taste receptors (T1R2/3), and duration from operation. For patients undergoing RMM, data leading to increased sodium-glucose co-transporter (SGLT1) collected matched the elapsed time since the surgical intervention in expression. We refer to this as the intestinal sweetness sensing (ISS) the RYGB group. Outcomes were compared preoperatively and at response. We believe ISS blunting due to isolation of proximal bowel least one year from the time of surgery. in RYGB contributes to metabolic benefits of this surgery. To see if a Results: 100 patients with T2DM undergoing RYGB with complete critical length of proximal bowel is necessary for ISS activation, we data were identified. Subjects were matched individually to RMM conducted the below experiments. (n=30), LAGB (28) and DS (n=27) with complete data. Mean Methods: Rats underwent duodenal cannulation and infusion of 0.3% follow-up was 13.4 months for all groups. Outcomes were analyzed saccharin (T1R2/3 agonist) or mannitol (control). Duodenum with using matched Student‟s T-Test, two tailed. Data are presented in the either the first 3cm of jejunum (Short Limb, SL), or the first 10cm of table below. jejunum (Long Limb, LL) were infused (n=7-8). Mid-jejunum (not exposed to the infusate) was harvested and analyzed for sweet taste receptor mRNA expression using QRT-PCR. Group Mean Outcomes Results: We confirmed our previous finding of SGLT1 up-regulation (*p<0.05 vs preop) following ISS activation in the LL group as compared with the SL HbA BM Med group. We also demonstrated a 3.7 fold increase in T1R2 mRNA 1c I Scor expression with saccharin vs. control in the LL group (p<0.05 - e Figure); however, this increase was not seen in the SL arm. α- RM 7.3 40.1 1.7 gustducin mRNA expression was not different between the two M to to to groups. (pre 7.4 40.4 1.9 Conclusion: Our findings show that a critical length of proximal to intestine needs to be stimulated to activate ISS, which seems to post) further augment itself by increasing expression of sweet taste RYG 7.3 42.4 2.4 receptors. Although contribution of roux limb length to outcomes has B to to to been studied previously, few have investigated the role of bilio- (pre 6.0* 27.6 0.7* pancreatic (BP) limb. These studies underscore the need for clinical to * studies to evaluate the optimal length of BP limb, especially in post) T2DM patients. p <0.0 <0.0 <0.0 RM 01 01 01 M vs RYG B (post op)

LAG 7.1 47.5 1.9 B to to to sustained drop in health expenditures relative to pre-surgery (pre 7.2 41.1 1.8 expenditures for the LAGB sample. Contrarily, payments for the to * comparison sample continued to rise. Focusing on direct medical, net post) costs of coverage for LAGB was reduced to zero approximately 4 RYG 7.1 46.4 1.8 years after placement and 2 years for the diabetes subsample. B to to to Incorporating indirect cost savings into the model further reduced the (pre 6.2* 31.6 0.9* breakeven time because of the high correlation (roughly 0.5) between to * medical expenditures, absenteeism, and presenteeism. post) Conclusion: These results suggest that the initial cost for LAGB, p 0.01 <0.0 0.00 roughly $20,000, may be recovered in a relatively short time horizon, LAG 01 4 especially for those with diabetes. Including indirect costs further B vs reduces the time to breakeven. RYG B O-014 What Happens With Loss Of Follow Up In Bariatric (post Surgery ? op)

DS 7.4 52.7 1.9 PRESENTER: Vincent Frering (CD2F) (pre to to to Co-Author: Eric Fontaumard1 to 5.3* 33.4 0.2* post) * RYG 7.5 50.4 2.4 CD2F, lYON, FRANCE; B to to to (pre 6.3* 33.6 1.0* Background: One of the concern in bariatric surgery is the lost of to * follow up. Some authors pointed that studies must be presented with post) complete follow up. But all the bariatric surgeons have encountered p DS 0.00 0.9 0.00 difficulties in their patient follow up. The aim of this study was to vs 3 4 assess what happened with patient who are lost of follow up. RYG Methods: In our center, 1300 patients have bariatric surgery per year. B Most of the current procedures are proposed. For gastric banding, (post follow up include post operative visit at 3 month, and annually. Band op) adjustment is done on patient request. During 6 months from July 2009 to December 2009, each patient with gastric band calling to the Conclusion: At one year postoperatively, the RYGB has a more office, who didn‟t give news since more than 1 year were submitted robust impact on HbA1c and medication score than the LAGB or to a questionnaire. Were excluded gastric by pass, and sleeve RMM for T2DM treatment. The DS has a more robust impact on gastrectomy. HbA1c and medication score than the RYGB when controlled for Results: During this time, 279 patients were included. Mean delay BMI, HbA1c and medication score preoperatively and despite no with no news was 31,4 ± 24,1 months. Patients didn‟t call because difference in weight loss. every thing was fine in 77% (n=222), 10 had their follow up with another physician, other had miscellaneous reasons (work, O-013 The Direct And Indirect Cost Implications Of Coverage pregnancy, family disorders..). They were satisfied with their weight For Laparoscopic Adjustable Gastric Banding (LAGB) loss in 88%. The reason for call was trouble with the band in 45% (mainly for deflation), other were calling for a fill, or before other PRESENTER: Eric Finkelstein (Duke-NUS) surgery. Half of the patients (48%) would like to be called for the follow up. Co-Authors: Ben Allaire3, Somali Burgess1, Brent C. Hale1 Conclusion: Most of patients doesn‟t want a follow up because they 1. Global Health Outcomes Strategy and Research, Allergan, Irvine, feel fine after gastric banding. CA, United States. 2. Medical School, Duke-NUS , Singapore City, Singapore. O-015 Incidentally Discovered Gastrointestinal Stromal Tumor 3. Social Policy, Health and Economics Research , RTI International, (Gist) During Gastric Banding Research Trirangle Park, NC, United States. PRESENTER: Danny Sherwinter (Maimonides Medical Center) Background: To quantify the financial impact of coverage for Laparoscopic Adjustable Gastric Banding (LAGB), including direct medical costs and changes in absenteeism and presenteeism. Co-Authors: Jesus Hidalgo1, Harry Adler1, Jerzy Macura1 Methods: Medical claims data for 9,000 LAGB patients and a propensity score matched control group were used to quantify medical costs and cost offsets resulting from LAGB for the full 1.Maimonides Medical Center, Brooklyn, NY; LAGB sample and for a subset with diabetes. Indirect cost savings were simulated based on reductions in direct medical expenditures Background: Gastrointestinal stromal tumors (GIST) are the most for the LAGB sample and cross sectional relationships between common mesenchymal neoplasms of the GI tract and may be more medical expenditures, absenteeism, and presenteeism using data from common in the obese patient population. Definitive treatment the Medical Expenditure Panel Survey and the National Health and involves margin free surgical excision. An incidentally discovered Wellness Survey. gastric GIST at the time of laparoscopic adjustable gastric band Results: In an average year, the typical LAGB candidate (BMI 35+ (LAGB) implantation presents a unique management dilemma. w/comorbidities) experienced $9,320 in medical expenditures, missed Methods: We present our experience with three patients incidentally 15 days from work, and had reduced productivity equivalent to 58 found to have a GIST during LAGB. We review the literature on the work days. After LAGB placement, there was an immediate and treatment of the incidentally discovered GIST and the safety of because it takes into account the height of the subjects. % Excess combining LAGB with other potentially contaminating intra- BMI Loss (%EBMIL) it is used to measure results in operated abdominal operations. patients but a BMI = 25 is used as an end point, and this is inadequate Results: Each of these patients underwent a wedge resection of the since it may be a correct one for morbidly obese patients but not in tumor followed by placement of the band. Disease free margins were the superobese. obtained and all have done well without infectious sequelae. Aim: To find an objective formula of Expected BMI (EBMI) for Conclusion: As the number of patients undergoing bariatric surgery ALL operated patients independent of race, social status and type of increases, incidentally discovered gastric GISTs will continue to rise. operation. The appropriate management of a small asymptomatic GIST remains Methods: 7140 patients with Initial BMI (IBMI) 35-70, and Final undefined. The placement of a lap band in conjunction with gastric BMI (FBMI) after > 3 years and different WL surgeries (Adjustable wedge resection appears to be safe but data is scarce. and non-adjustable bands, RNY with and without bands, BPD and DS), operated in different centers (1 Canadian, 2 USA, 1 Colombia, 1 Germany, 1 Italian and 8 in Spain) were evaluated. A regression O-016 Duet TRSTM Reload Is A Preloaded Absorbable lineal statistic analysis to find a formula to calculate EBMI in each Reinforcement Material On An Endoscopic Stapler That Is patient was used. “Expected” is the real value obtained in many Straightforward And Effective For Gastric Pouch Creation. individuals after measuring pre and post BMI at > 3 years. Results: The formula obtained is EBMI = IBMI*04 +11.756 and then PRESENTER: Aurora Pryor (Duke) the “Expected percentage of the excess BMI loss” can be figured as E%EBMIL = = (IBMI – final BMI) / [(IBMI – (IBMI*0.4 +11.756)] x 100, using instead of the fixed figure of BMI = 25 the EBMI as Co-Authors: NIng Jiang1, Eric J. DeMaria1, Dana D. Portenier1, (IBMI*0.4 +11.756). Ranjan Sudan1, Alfonso Torquati1 A second type of formula takes into account the different surgical techniques and is EBMI = IBMI*0.435 + 13.251 + the effects of an 1. Duke, Durham, NC, United States. specific technique and have required some adjustment values ranging from -3.4 to +8.3 depending on the technique used. Conclusion: One “expected” BMI figure, instead the fixed one of Background: Preloaded absorbable reinforcement material (PARM) BMI = 25, may estimate more accurately %EBMIL success of failure (Duet TRSTM, Covidien, North Haven, CT) is theorized to facilitate in all bariatric operations depending on the Initial BMI of the patients hemostatic staple lines without added time or user error. We and can be used in patients with different social status, different undertook a prospective trial of PARM in gastric pouch creation countries and surgeons. during Roux-en-Y gastric bypass (RYGB). Methods: Consecutive patients presenting for non-revisional RYGB with BMI<60 were approached for enrollment. Demographics and O-018 Management Of Obstructive Sleep Apnoea (OSA) In A pre-operative labs were recorded. Patients underwent laparoscopic UK Specialist Bariatric Unit- ITU And HDU Care Are Not RYGB using the surgeon‟s standard technique. All gastric pouch Necessary transections were created using linear staplers with PARM. OR time, peri-operative and post-operative complications were recorded. PRESENTER: Conor Magee (Gravitas Centre for Bariatric Patients were assessed at up to 1 month after surgery. Surgery) Results: Thirty patients underwent surgery in the study. Twenty-four have completed their post-operative visit. 5 Men and 25 Women were enrolled. Pre-operative BMI averaged 46 (38-62). Post-operative Co-Authors: Jayne M. Brocklehurst1, Simon Weaver1, Shafiq BMI averaged 42 (34-56) at 3 weeks post-operative. Javed1, Robert Macadam1, Euan Shearer1, David Kerrigan1 Eighty-eight PARM reloads were used in the study. Eighty-five (97%) of the PARM staple fires (97%) appeared ideal and did not 1. Gravitas Centre for Bariatric Surgery, Liverpool, 0, United require supplemental clips or suture reinforcement. Only one firing Kingdom. (1%) was felt by the surgeon to require over-sewing. One cartridge had the PARM dislodge during placement and one failed to open. OR time averaged 99 minutes (62-165). Average length of stay was 1.3 Background: Whilst the UK and the USA share an obesity epidemic days (1-2). with patients exhibiting similar co-morbidities, the UK NHS has a Three adverse events were seen. Two were anastomotic strictures not paucity of elective critical care beds. This means that management of involving the PARM and one was a portal vein thrombosis treated conditions such as OSA in critical care facilities can be difficult to with anticoagulation. There was no leak and no transfusion achieve. Accordingly our unit has managed such patients in a level I requirement in the study population. observation ward with “step-up” to level II/III as required. We Conclusion: PARM can be used safely and efficiently with a low present the results of our 12-year series. complication rate for gastric pouch creation. Methods: Prospective database of patients undergoing bariatric surgery. Patients with OSA received supplemental oxygen via mask with continuous pulse oximetry. If the oxygen saturation fell below O-017 ―Expected‖ BMI After Bariatric Surgery the pre-operative level then patients used their CPAP machine/ oxygen at 2-3L/min. PRESENTER: Aniceto Baltasar (San Jorge Clinic) Results: OSA was present in 127/1373 patients. Of those with OSA, 58% were male and the median BMI was 54 (35-95.6). No patient with OSA needed ventilation or tracheostomy. Co-Authors: Nieves Pérez1, Carlos Serra1, Marcelo Bengochea1, Conclusion: Laparoscopic bariatric surgery for patients with Rafael Bou1 obstructive sleep apnoea is safe and does not require routine use of level II/III critical care facilities. 1. Surgery, San Jorge Clinic, Alcoy, Alicante, Spain. Median Median In Patient Cases where Operation n Background: BMI = Kg /m2 is the best measurement of obesity BMI Length of Mortality ITU required Stay for ventilation approaches for several applications. (days) Lap. Gastric O-020 Intragastric Balloon Treatment Role On Gastric Banding 25 47.9 1 zero 0 Band Success Predictivity: Italian Multicentric, Retrospective Study On 668 Patients Lap Gastric 43 55.7 3 zero 0 Bypass PRESENTER: Alfredo Gencon (Surgery Department, Sapienza Lap. Duodenal 17 60.3 3 zero 0 University, Rome) Switch Lap. Sleeve 29 53.3 3 zero 0 Gastrectomy Co-Authors: Barbara Bindi2, R. Bisulli2, Vincenzo Borrelli2, Luca Busetto2, Rita Conigliaro2, Pietro Forestieri2, Angelo Gardinazzi2, 2nd Stage Lap. 3 49.8 3 zero 0 Cristiano Giardiello2, Marcello Lucchese2, Piero Maida2, Maria Gastric Bypass Marino2, Roberta Maselli2, Giancarlo Micheletto2, M. Oppezzi2, 2nd Stage Lap. Luca Pecchioli2, Italo Piccini2, Francesco Puglisi2, Angelo Rossi2, Duodenal 8 55.3 2 zero 0 Giuseppe Rovera2, Marco Zappa2, Antonio Susa2, Fiore Torchia2, Switch Maurizio Zilli2, Nicola Basso2 Open Gastric 2 54.5 3 zero 0 Bypass 1. Surgery department, sapienza university, rome, Rome, Italy. 2. ITALIAN BIB STUDY GROUP, Rome, Italy.

O-019 Durability Of Endoscopically Placed Sutures Utilized For Bariatric And Non-Bariatric Applications Background: Aim of this study is to evaluate BIB results predictivity on Lap-Band results, at 3 years follow-up. Time elapsed between BIB

removal and Lap-Band placement and its influence on Lap-Band PRESENTER: Matthew Brengman (St. Mary's Hospital-Bon results were evaluated. Predictivity of sex and age on Lap-Band Secours) success were evaluated. Co-Authors: Gregory L. Schroder1, Peter M. Denk2, Lee L. Methods: Data were collected from 25 Italian centers. Weight loss Swanstrom3 was evaluated in terms of BMI, %EWL and %EBL at BIB-removal and 1 and 3 years after Lap-Band. EWL%≥25 was defined success at BIB removal (Group A), EWL%≤24.9 failure (Group B). 1 year after 1. Department of Surgery, St. Mary's Hospital-Bon Secours, surgery EWL% ≥25 and 3 years EWL% ≥50 were defined Lap-Band Richmond, VA, United States. success. 2. Bluegrass Bariatric Surgical Associates, Lexington, KY, United Results: EWL% of 668 patients (494 F/174M) at BIB removal was States. 36.7 (Group A) and 15.7 (Group B). After a mean time of 7.3 months 3. Dept. Minimally Invasive Surgery, Legacy Health System, all patients underwent Lap-band (Group A: EWL% 20.7; Group B: Portland, OR, United States. EWL% 8.6). At 1 and 3 years Lap-Band follow-up EWL% was 43.8, 32.5 and 52.3 and 40.9 in group A and B respectively. The two Background: An endoscopic operating platform technology which groups had a significant weight loss difference (p<0.01). EBL% incorporates self-expanding sutured anchors was clinically utilized to evaluation confirmed significance, sex had no influence, while age repair dilated stoma and pouch tissue post-Roux-en-y gastric bypass significance was inversely related to the Lap-Band results (RYGB), repair gastro-gastric fistulas (GGFs), close gastrotomies, (p<0.0001). and revise failed Nissan fundoplications. 6-12+ month endoscopies Conclusion: BIB success (in terms of EWL%) predict Lap-Band were done to document gastric fold durability. success at medium term. BIB patients with EWL≥25% will have Methods: Prospective IRB approval was obtained for all applications significantly better results after Lap-Band (p<0.03). Weight regain using the endoscopically placed tissue anchors. 116 patients after BIB removal and surgery has no influence on Lap-Band underwent repair of their dilated stoma and/or pouch post Roux-en-Y outcome. Patients younger have significant higher probability to have bypass as part of a 9 center registry. 3 GGFs were repaired. 5 successful Lap-Band results. gastrotomies were closed following trans-gastric cholecystectomy. 2 patients had an endoscopic repair procedure for failed Nissan. O-021 Temporary Weightloss Management With The BIB Durability of tissue remodeling was assessed via follow up Intragastric Balloon System As Introducing Or Bridging To endoscopy. Bariatric Surgery Results: 112/116 (96%) RYGB registry patients had at least one anchor placed in the gastrum. 65/112 underwent 12 month endoscopy with 60/65 (92%) endoscopies confirming the continued presence of PRESENTER: Rafael Blanco Engert (Dornbuschklinik visible anchors/tissue folds. There were no post-operative Chirurgische Praxis am Dornbusch) complications to date in any of these patients. 6 month endoscopic follow-up of the GGF repairs showed durable closure in 3/3 patients. Late follow-up showed failure in 2/3 closures (mean 13 months). Co-Authors: Sylvia Weiner 2, Richard Merkle 3, Rudolf Weiner2 Endoscopy confirmed durable gastrotomy closure at ≥12 months in 5/5 NOTES cholecystectomy patients. Endoscopic images post 1. Ambulantes Adipositaszentrum, Dornbuschklinik Chirurgische Nissan repair demonstrated durable tissue folds at 6 months in 2/2 Praxis am Dornbusch , Frankfurt, Hessen, Germany. patients with normal ph and improved GERD scores (0, 1). 2. Visceral and Bariatric Surgery , Krankenhaus Sachsenhausen , Conclusion: Tissue fold durability at 6-12+ months with this Frankfurt , Hessen, Germany. endoscopic suturing system for bariatric revision, reflux, and 3. Viszeral-chirurgische Abteilung, Medizinische gastrotomy closure procedures has been very promising. This system KompetenzzentrumMünchen GmbH , Robotic Surgery Clinic, offers a less invasive alternative to current laparoscopic surgical München, Bayern, Germany. R. Merkle , Viszeral-chirurgische Abteilung, Medizinische KompetenzzentrumMünchen GmbH , Robotic Surgery Clinic, München, Bayern, GERMANY; PRESENTER: Kalpana Devalia (Homerton University Hospital)

Background: Since 1997 the BIB-Intragastric Balloon (Bioenterics) Co-Authors: Mehtab Rahman1, Samrat Mukherjee1, Harun is a helping tool in our Bariatric Experience. Indications for BIB Thomas1, Kesava Reddy Mannur1 Placement are Patients BMI range 30- 40 with / without co morbidities, those who refuse Bariatric Surgery (35- >40) or would 1. Bariatric Surgery, Homerton University Hospital, London, United benefit for a bridge to bariatric Surgery while considering their Kingdom. options. Even Patients who need cardiovascular, orthopedic or other surgery but whose excessive weight puts them at risk and or reduces Background: The prevalence of obesity is continuing to increase and likelihood of a good outcome. so is its incidence in patients over the age of 60. Bariatric surgery in Methods: Descriptive retrospective study analizing risk and the 〉60 years old group with morbid obesity is a relative complication profile of patients undergoing the BIB Gastric-Balloon contraindication by some centres in view of greater risk and Procedure . perceived poor results. Results: 843 patients has been treated with the BIB Intreagastric Methods: We reviewed our prospective database of bariatric surgery. Balloonsystem under supervision and multidisciplinary care .Mean From January 2005 to February 2009, 30 patients 〉60 years old weight loss was 20.8 KG (44.3Pounds )in 196 days BIB in place . underwent bariatric surgery. We evaluated the outcomes in terms of Complications were divided in mayor(life threatening)0.2 % and postoperative complications, hospital stay, weight loss and resolution minor 4.3 % , mortality was 0% of co morbidities in patients 〉60 years old who underwent bariatric Conclusion: The BIBGastricballoon System is a valid helping tool in surgery multidisciplinary weight loss management and should be a specific Results: 21 patients had a Roux-en-Y Gastric Bypass, 6 had a sleeve option in the Bariatric Surgeons Portfolio even if it is only a gastrectomy and 3 had a gastric band operation. The median age was temporary tool. 61 (range 60-70years). The median BMI was 44.5 kg/m2 (range 37.9- 64.1). 12 patients were type 2 diabetics, 10 had significant sleep O-022 Obesity Related Publications By Bariatric Surgery Center apnoea, 13 had hypertension, 6 had ischaemic heart disease and small Of Excellence Surgeons number of patients had asthma, depression and arthritis. Diabetes resolution or improvement was seen in 80% of patients and resolution of sleep apnoea was seen in 85% of patients. The average hospital PRESENTER: Atul Madan (Beverly Hills Surgery Center) stay was 2.5 days and there were no complications seen in this group. There were no deaths reported at 30 days. The median BMI at one year follow up was 31.8kg/m2. Co-Authors: Salman Khan1, Pejman Samouha1, Michael Omidi1, Conclusion: Bariatric surgery is safe and feasible in the elderly. The Julius Gee1, George Tashjian1, Julian Omidi1 outcomes of bariatric surgery in the elderly are comparable to the younger population. Age should not be a contraindication to bariatric 1. Beverly Hills Surgery Center, Beverly Hills, CA, United States. surgery.

Background: Bariatric Surgery Centers of Excellence (COE) were O-024 Using 3D Scanning Technology To Document The Pre- developed to ensure high quality of bariatic surgery clinical care to Operative Bariatric Patient: Automatic Measurement Extraction patients. Publications in obesity surgery and research are important in Versus The Tape Measure helping guide clinical care. This study was undertaken to investigate the hypothesis that most COE surgeons would have obesity related publications. PRESENTER: Stephen Wohlgemuth (Sentara Hospital System) Methods: Surgeons listed as a COE surgeon on the Surgical Review Corporation website were included in this study. Publications were queried for each COE Surgeon on PubMed from January 2000 to Co-Author: David B. Stefan1 October 2009. Abstracts were explored and only those publications related to bariatric surgery or obesity were included in this study. 1. Novaptus Systems, Inc, Chesapeake, VA, United States. Basic science and clinical reports were included. Publications were 2. Metabolic and Weight Loss Surgery Center, Sentara Hospital not graded by their quality. System, Norfolk, VA, United States. Results: There were 654 surgeons included in this study. The mean (median) publications for the COE surgeons were 2.5 (0). There was Background: Measuring pre-operative bariatric patients a wide range of publications per COE surgeon (0-67) and 60% of anthropometrically, that is, with a tape measure has always proved to COE surgeons did not publish even one article. Only 42 (6%) COE be a difficult task. Take several different nurses independently surgeons had 10 or more obesity related publications and they measuring the same bariatric patient and the measurement results will represented 57% of the total obesity related publications by COE vary, often greatly. A new technology has been introduced that surgeons. creates an accurate 3D body model using a 3D whole-body scanner. Conclusion: Most COE surgeons do not publish their results or any Measurement templates can be applied to this body model to other publications related to obesity. In fact, most of the publications automatically extract pertinent measurements with consistent and come from only a few COE surgeons. All COE surgeons should be repeatable results, eliminating measurement errors. encouraged to publish their results and findings to decrease the Methods: A group of four separate nurses were given basic guidance potential of publication bias. on how to measure a subject. Ten bariatric patients were then measured separately by nurses and the measurement results were O-023 Outcomes Of Bariatric Surgery In Patients More Than 60 recorded. Measurements recorded included the neck, chest or bust, Years Old waist, hips, right thigh and left bicep. These bariatric subjects were then scanned using the 3D body scanner. An accurate body model was produced. A measurement extraction profile was programmed to automatically extract the same measurements taken by the nurses. Results of the automatically extracted measurements were compared Disappered or improved [%] 87.5 100 to the measurements gathered anthropometrically by the group of DM nurses. No change [%] 12.5 0 Results: The measurements recorded separately by the nurses showed Disappered or improved [%] 66.6 80 significant inconsistency when compared to each other and to the HTN same measurements automatically extracted by the scanning No change [%] 22.2 20 software, indicating the fallibility of measuring a bariatric subject Disappered or improved [%] 71.4 33 consistently by human means. A statistical analysis was performed. Hypercholesterolemia No change [%] 8.6 66 Conclusion: Introduction of 3D scanning and measurement technology heralds an accurate and repeatable method of Disappered or improved [%] 20 75 Hypertriglyceridemia documenting the physical dimensions of the bariatric patient. This is No change [%] 60 25 useful for all stages of the bariatric weight loss process. Disappered or improved [%] 50 100 Hyperuricemia No change [%] 50 0

O-026 Sleeve Gastrectomy Does Not Induce Gastroesophageal Reflux Disease: Pre- And Postoperative Evaluation By Pre- And Postoperative 24-H Ph-Multichannel Intraluminal Impedance And Combined High Resolution Manometry And Impedance

An example of automatic measurement extraction from a pre- PRESENTER: Gianmattia del Genio (University of Naples) operative bariatric patient's 3D body model. Compare this to 1 1 measurements taken manually by various nurses. Co-Authors: Salvatore Tolone , Luigi Brusciano , Luca Montesarchio1, Antonio D'Alessandro1, Alberto del Genio1

O-025 Results Of Laparoscopic Sleeve Gastrectomy (LSG) In 1. Surgery, University of Naples, Napoli, Italy. The Elderly

Background: Sleeve gastrectomy is currently gaining popularity due PRESENTER: Asaf Kedar (Hadassah-Hebrew University to an excellent postoperative weight loss. However, some concerns Hospital) have been raised on the increased risk of postoperative gastroesophageal reflux disease (GERD) due to the fundus removal or to the section of the sliding muscular fibers of the gastro- Co-Authors: David Hazzan2, Chaya Schweiger1, Samir Abu- esophageal junction. Combined multichannel intraluminal impedance Gazala1, Naama Kafri3, Avraham I. Rivkind1, Andrei Keidar1 and pH (MII-pH) is the most sophisticated instrument for studying GER. Over 24 h of monitoring, it enables detection of every 1. General Surgery, Hadassah-Hebrew University Hospital, antegrade or retrograde movement into the esophagus. Furthermore, Jerusalem, Israel. using a pH sensor located in the catheter, each movement can be 2. General Surgery, Carmel Medical Center, Haifa, Israel. assigned a degree of acidity. 3. Bariatric Clinic, Lin Medical Center, Haifa, Israel. Methods: From September 2006 15 consecutive patients (10 women and 5 men; mean age, 42.1 ± 12.5 years; range, 22–62 years) underwent laparoscopic Sleeve Gastrectomy. Evaluation of the

symptoms was accomplished by a standardized questionnaire based Background: The effect of LSG in the elderly population is largely on the modified DeMeester symptom scoring system. Pre and unknown. We here in present our experience with this procedure in postoperatively, all patients underwent upper endoscopy, esophageal the elderly population. combined high resolution manometry and impedance and MII-pH. Methods: Prospective cohort of patients older then 60 years that Results: The evaluations were performed a median of 15 days (range, underwent LSG. All data was collected prospectively. 2–45 days) before the sleeve and 12 months (range, 8–15 months) Results: From 2006 to 2010, 313 LSG have been performed at 2 afterward. Mean excess weight loss was 56%. The MII-pH confirmed medical institutes, of them 22 (7%) patients are above the age of 60 the postoperative absence of pathologic acid and non-acid reflux (p= (60-72). Nine and 12 of the patients have follow-up of 6 and 12 n.s.). The bolus transit time improved at HM-MII (p < 0.05), the LES month respectively, total of 14 patients included in this work. pressure did not change after surgery (p=n.s.) Preoperative BMI was 42 (35-60), excess weight 48.8Kg (26.8-78.9). Conclusion: Sleeve gastrectomy does not increase reflux in patients Ten out of 14 patients had diabetes mellitus (DM), all but one patient with a normal esophageal peristalsis and lower esophageal sphincter had hypertension (HTN), 10 patients had hypercholesterolemia, 5 had and without preoperative GERD. The absence of gastric fundus as an hypertriglyceridemia and 2 had hyperuricemia. antireflux mechanism is probably balanced at 1 year follow-up by the There was no mortality, morbidity was registered: One patient had to increased volume of the remnant stomach and the weight loss. be reintubated due to atelectasis. One patient needed 1 packed cell due to bleeding in port site. One patient had PE and wound infection. One patient had stricture of the sleeve and suffer from severe GERD, O-027 Results Of Sleeve Gastrectomy—Data From A Nationwide two patients had re-hospitalization due to vomiting and weakness. Survey On Bariatric Surgery In Germany More data is shown in the table attached. Conclusion: LSG is a safe and effective for the obese elderly with PRESENTER: Christine Stroh (SRH Wald-Klinikum Gera) decrease in weight and improvement of comorbidities.

Co-Author: Christine Stroh1 Month follow-up 6 12 Average % Excess Weight Loss 69.2 59.8 C. Stroh, , SRH Wald-Klinikum Gera, Gera, GERMANY; Conclusion: LSG reduces the risk of CHD in morbidly obese patients with hypertension and dyslipidemia.Further studies with a larger sample & long term results are needed. Background: Beginning January 1, 2005, the status and outcomes of bariatric surgery were examined in Germany. Data are registered in cooperation with the An-Institute of quality assurance in surgery at O-029 Metabolic Outcomes Of Sleeve Gastrectomy In Patients the Otto-von-Guericke- University Magdeburg. The objective of this With Impaired Glucose Metabolism study was to examine the morbidity and mortality rates secondary to sleeve gastrectomy (SG) in Germany since 2006. PRESENTER: Hanns Lembach (Department of Surgery Methods: Data collection occurred prospectively in an online data University Hospital) bank. All primary bariatric procedures performed were recorded as were all re-operations in patients that had already undergone a primary operation. Specific data compiled on the sleeve gastrectomy Co-Authors: Enrique Lanzarini1, Attila Csendes1, Juan Carlos procedure were evaluated with a focus on operative details and Molina1, Italo Braghetto1, Luis Gutierrez1 complication rates. Results: The total study cohort contains more than 9.500 patients. From January 2006 to December 2009, more than 1000 sleeve 1. Department of Surgery University Hospital, Santiago, Chile. gastrectomy procedures were performed in the 20 hospitals participating in the study. The mean body mass index (BMI) of all Background: Sleeve Gastrectomy (SG) has been accepted as a patients was 48.8 kg/mxm. The BMI of patients undergoing SG was definitive procedure for weight control in obese patients. 54.5 kg/mxm. In total, 73.8% of the patients were female and 26.2% Furthermore, comorbidities including Type 2 Diabetes (T2DM) and of the patients were male. There were no significant differences Insulin resistance (IR) have also shown improvement. between patients undergoing SG. The general complication rate after Objective: Assess the effect of SG in metabolic and glycemic control SG dropped down from 14.1% 2007 to 7,0% 2008. The postoperative parameters in patients with impaired glucose metabolism. mortality rate was 0.4%. Conclusion: The complication rate during the first 3 years after SG in Methods: Revision of clinical files of 21 patients with T2DM or IR Germany is similar to that published in the literature. In order to who underwent SG between 2005 and 2009. The t-student test was improve the quality of bariatric surgery, an evaluation of data from a used to analyze data. German multicenter trial is necessary to evaluate the position of SG Results: There were 12 patients in T2DM group and 9 in IR group, in the bariatric algorithm. and average preoperative BMI was 35.8 and 33.6 respectively. The average evolution time of T2DM was 3.3 years and 75% used oral O-028 Cardiovascular Risk Reduction After Lsg (Laparoscopic diabetes medication. Preoperative blood glucose level (BGL) was Sleeve Gastrectomy ) Using Framingham Score. 150,6mg/dl for T2DM, and 99,2 for IR. Average postoperative follow-up was 22.2 months. During first year of Follow-up, T2DM patients decreased their BMI to 28.2, and BGL descended to 88 PRESENTER: Jayashree Todkar (Ruby Hall Clinic) mg/dl, both remaining stable afterwards. In the IR Group, BMI fell to 23.4 and BGL to 76 mg/dl during the first year. In T2DM patients, Glycosylated Hemoglobin decreased from 7,2% to 4,1% during the Co-Authors: Shashank S. Shah1, Poonam S. Shah2, Sushilkumar first year. In IR patients HOMA score descended from 3,98 to 0,23. Dubey2, Michel Gagner3 Cholesterol levels didn‟t show significant modification, whereas triglycerides decreased from 219 to 150 mg/dl in the T2DM group 1. Surgery, Ruby Hall Clinic, Pune, Maharashtra, India. and from 164 to 88 mg/dl in the IR group. 2. Surgery, Laparo-Obeso Center, Pune, Maharashtra, India. Conclusion: SG is effective in controlling weight, and significantly 3. Herbert Wertheim college of medicine, Florida international improves glucose metabolism in patients with T2DM and IR, but is University, Miami, FL, United States. ineffective improving lipids levels.

Background: Morbid obesity, hypertension , dyslipidemia are known O-030 Sleeve Gastrectomy In Type 2 Diabetic Obese Patients to increase coronary heart disease (CHD) risk. Improvement in the above can reduce this risk. FRAMINGHAM RISK SCORE predicts absolute risk of CHD in this population. This study aims to evaluate PRESENTER: Marcos Berry (Clinica Las Condes) changes in absolute CHD risk before and after laparoscopic sleeve gastrectomy(LSG ). Methods: Total 87 obese hypertensive patients with dyslipidemia Co-Authors: Nelson Bello1, Lionel Urrutia1, Marcelo Fajardo1 underwent LSG at laparo-obeso center from 2004 till 2008.This is the retrospective study of the prospectively evaluated 32 patients using FRAMINGHAM RISK SCORE preoperatively & at 36 months after 1. Clinica Las Condes, Santiago, Chile. LSG. For analysis paired T test was used. Results: The mean age was 44±20 yrs .N =32. The mean preop Background: Sleeve gastrectomy (SG) has been recongnized as a systolic BP(136.4 mm of Hg), total cholesterol( 182.8 mg%),HDL good treatment option for obesity and its comorbidities. SG became (43.1 mg% ),triglycerides (164.1 mg% ),CHD risk (14.19 ) ,Fatal the most widespread procedure in our country with excellent results CHD risk (8.98 ),stroke risk (6.71) and fatal stroke risk (1.37 )was in weight loss and acceptable morbimortality. The aim of this report compared to mean postop systolic BP(127.6 ), total cholesterol(178 is to present our experience in treating obese type 2 diabetic patients ),HDL (44.7 ),triglycerides (122.9),CHD risk (11.11) ,Fatal CHD risk with SG in relation to %EWL, metabolic performance after surgery ( 6.95),stroke risk ( 6.69) and fatal stroke risk (1.31).Statistically and morbimortality. significant difference was found between pre and post operative Methods: Methods: Prospective case series of 20 obese well systolic BP(p<0.001), triglycerides(p=0.01) ,CHD(p=0.008) & fatal controlled type 2 diabetic patients who underwent SG between April CHD (p=0.005)risk. Difference between pre and post operative total 2006 and August 2009 and who were followed with a specific cholesterol,HDL ,stroke risk and fatal stroke risk was not statistically protocol. significant. Results: 13 male and 7 females patients were operated. Mean preop Santiago, Chile. BMI was 37 (31-51). Mean preop HbA1c was 6,6% (5,5-7,9). No patient was treated with insulin on a regular basis. At six month of Background: Laparoscopic Sleeve gastrectomy (LSG) has become an follow-up the mean BMI was 29.5, the %EWL was 64% in the same alternative as a primary bariatric procedure. The aim of this study period, the mean postop HbA1c was 5,6%. The mean preop fasting was describe the results of this technique 1000 consecutive patients. glucose level was 128mg% (91-190) vs 91,7 mg (81-103). The preop Methods: We conducted a review of our prospective electronic mean fasting insulin level was 40 uU/ml (17-108) compared to 18,5 database of patients undergoing LSG from August 2005 to December uU/ml at six months after SG. At six months, 19 patients had no 2009. Demographic, surgical results, complications,percentage of farmacological treatment (95%) and 1 lowered the doses. 1 patient excess weight loss (%EWL) and comorbidities were assessed. (5%) presented hemoperitoneum that did not required reoperation. Results: Mean preoperative age was 36.9±11 years (77% female). Conclusion: Conclusions: SG is a safe and effective treatment for Mean preoperative BMI was 37.2 ± 4.6 kg/m2 (30.5 - 56). Mean obesity and shows good results in obese well controlled diabetic operative time was 77±31 minutes 40-200). There was 1 conversion patients. to open surgery due to splenic bleeding. Mean hospital stay was 3 ± 2.1 days (2-77) and time to oral intake 1.2±0.4 days. Postoperative O-031 Sleeve Gastrectomy –Late Results complications occurred in 33 patients (3.3%).The most common complication was portomesenteric thrombosis (1%) and gastric staple leak (0.7%).Seven patients required reoperation due to leaks, PRESENTER: Rudolf Weiner (Krankenhaus Sachsenhausen) bleeding and antral stenosis. The hospital readmission rate was 2.5% . The resolution of comorbid conditions was observed: Hypertension (62.5%), Type 2 diabetes (91%), Insulin resistance (93.1%), 1. Surgery, Krankenhaus Sachsenhausen, Frankfurt am Main, Dyslipidemia (84.8). Percentage of excess weight loss for patients at Germany. 6, 12 and 24 months was 89%, 88% and 85% respectively. Conclusion: LSG has become an acceptable primary bariatric Background: The efficacy of laparoscopic sleeve gastrectomy (LSG) procedure with low morbidity , resolution of comorbid conditions and for morbidly obese patients in the long-ter, follow-up have not been good weight loss after 2 years. investigated. Methods: This is a prospective study of a total number of 746 pts who underwent isolated LSG. 22 pts had a follow-up of 8 years, 108 O-033 Laparoscopic Sleeve Gastrectomy As A Definite of 5 years and more. The 22 pts with 8 years follow-up (fu) and 24 Treatment Of Morbid Obesity: Experience In The University pts with 5 yrs fu and high BMI were scheduled for a two-step LBPD- Hospital Of Crete DS, but rejected the second step after one year. Results: The maximum of BMI-drop was seen at two years after LSG. Weight loss stopped mean 13,2 months p.o. 42% of all pts PRESENTER: Markos Daskalakis (University Hospital starting weight regain after 2 years and 82 % after 5 yrs. The BMI- Heraklion) loss war median 16 points. The EWL % was at 2 years 59 % 45 % 5 yrs and 36 % after 8 yrs. The mean sleeve volume increased from 44.4 ccm up to 186 ccm (8 yrs). The most common cause for weight Co-Authors: Ioannis Askoxylakis1, Maria Metaxari2, Efstathios regain was prepyloric dilatation (54%), extension of the incomplete Dimitriadis1, Anastasia Peppe1, John Grammatikakis3, John resected fundus (8%) and changing of eating behaviors. A total of 42 Melissas1 patients underwent a second stage procedure within a period of 5 years (4 redo-sleeves, 12 LBPD-DS, 26 LRNYGB and Omega-loop- 1. Bariatric Unit, Department of Surgical Oncology, University Bypass). Hospital Heraklion, Heraklion, Greece. Conclusion: The LSG is excellent stage procedure for high BMI- 2. Anesthesiology, University Hospital Heraklion, Heraklion, Greece. patients and effective in lower BMI-classes as well. The most 3. Radiology, University Hospital Heraklion, Heraklion, Greece. common problem in the long-term follow-up seems to be the praepyloric dilatation with increase of the gastric volume from approx. 40 ccm up to 140 ccm and more. Therefore the reduction of Background: The aim of this study was to evaluate the outcomes and the antrum volume should be considered and studied in prospective perioperative safety for laparoscopic sleeve gastrectomy (LSG) as a studies. A statistically significant improved health status and quality standard bariatric procedure. of life were registered for all patients. The generally introduction of Methods: We performed a retrospective review of the prospectively LSG as a one-stage restrictive procedure in the bariatric field can be collected data of all patients who underwent LSG for the treatment of considered only if the procedure is standardized and more long-term morbid obesity at our institution from January 2005 to February results are available. 2010. Results: Data from 151 consecutive patients (male 35.4%, female 64.6%, mean age 37.6 ± 9.6 years, mean preoperative BMI 48.2 ± 7.3 O-32 Laparoscopic Sleeve Gastrectomy As A Primary Bariatric kg/m2, range: 33.5-74 kg/m2), who were operated on by a single Procedure. Results In 1000 Consecutive Patients surgical team, were analyzed. There was no early or late mortality. Early complications were noted in 15 cases (11.5%) including 10 Presenter: Camilo Boza (Pontificia Universidad Católica de cases (7.7%) of hemmorhage, 1 case (0.7%) of leak and 4 cases Chile) (3.0%) of febrile episode associated with atelectasis. In 1 case (0.7%) reoperation was performed. Mean operative time was 105 ± 30 min and overall, mean length of stay was 6.3 ± 2.6 days. Mean BMI and Co-Authors: Cristian Gamboa1, German Viscido1, Fernando %EBL for patients at 1 year post-LSG were 33.9 ± 6.2 kg/m2 and Pimentel1, Pablo Becerra1, Alejandro Raddatz1, Gustavo Perez1, 61.8%, respectively. Mean BMI and %EBL for patients 2 years post- Andrea Vega1, Luis Ibanez1 LSG were 32.3 ± 5.9 kg/m2 and 66.7%, respectively. Analysis of the %EBL during further follow-up at annual intervals showed stabilization in body weight thereafter. The mean %EBL for the third 1. Digestive Surgery, Pontificia Universidad Católica de Chile, year and fourth year of follow-up was 68.4% and 67.4%, respectively. Conclusion: LSG constitutes a potentially safe anti-obesity procedure effect. with acceptable morbidity. Our results are comparable to those of Methods: Methods: Twenty-six patients underwent an LSG/DJB other bariatric procedures. The effect of this weight-loss procedure is from April 2007. The mean preoperative weight and BMI were more rapid during the first postoperative year followed by a more 111.2+-19.1 kg and 42.5+-6.9 kg/m2, respectively. They consist of 3 gradual weight loss during the second postoperative year and cases of BMI less than 35 and 10 cases of between 35 to 40, 13 cases stabilization thereafter. Additional long-term studies are needed to over BMI 40. There were 15 T2DM and 8 IGT cases. evaluate the efficacy of the procedure. Results: The weight loss and excess BMI loss at the 3-, 6-, 9-, 12-, 18-months follow-up points were 18±4.5, 25±7.5, 27±6.2, 31±8.2, 37±5.0kg and 47±29, 63±23, 66±23, 78±24, 96±10%, respectively. O-034 Sleeve Gastrectomy With Enteral Bypass (Sgebp): Results Remission rate of T2DM were 93%. HOMA-IR at Pre, 3-,6-,9-,12- In A Prospective 5 Years Follow-Up Case Series. ,18-months were 7.0±7.7, 3.9±3.3, 2.6±2.2, 1.6±0.9, 1.7±0.8 respectively. There was significant deference from 3 months, on the PRESENTER: Munir Alamo (Hospital Dipreca) other hand, our results of LSG indicated that significant reduction of HOMA-IR after LSG occurred form 6 months after surgery. Postoperative 75g OGTT reveals that LSG/DJB can improve both Co-Authors: Jose Gellona2, Cristian Astorga1, Matias Sepulveda1, HOMA-IR and Insulogenic Index ( Early phase Insulin secretion). Carlos Manterola3 Even in the patients with pre-ope C-peptide level less than 3, they could have a good remission of T2DM after LSG/DJB. 1. Surgery, Hospital Dipreca, Santiago, Chile. Conclusion: LSG/DJB can achieve good remission of T2DM with 2. Emergency, Clinica Tabancura, Santiago, Chile. improvement of early phase insulin secretion. 3. Surgery, Universidad de la Frontera, Temuco, Chile. O-036 Weight Loss After Duodenal Switch Without Gastrectomy Background: To report results in terms of weight loss, BMI, For The Treatment Of Severe Obesity: Review Of A Single morbidity and improvement of comorbidities with SGEBP, a Institution Case Series Of Duodeno-Ileal Intestinal Bypass restrictive and malabsorptive surgical technique for morbid obesity treatment. PRESENTER: Fady Moustarah (Cleveland Clinic Foundation) Methods: Prospective case series. Patients with body mass index (BMI) > 40 kg/m2 or > 35 kg/m2 with comorbidity underwent a SGEBP between February 2004 and August 2009 via a laparoscopy Co-Authors: Simon Marceau2, Stefane Lebel2, Laurent Biertho2, or laparotomy at DIPRECA Hospital, in Santiago, Chile. SGEBP Frederic-Simon Hould2, Picard Marceau2, Simon Biron2 consists in create a gastric tube preserving pylorous and then performing a bypass of proximal small bowel, by performing an 1. Bariatric and Metabolic Institute, Cleveland Clinic Foundation, anastomosis 30 cm distal to the treitz angle, leaving 300 cm of non Cleveland, OH, United States. absorbing bowel. 2. Département de chirurgie, Institut Universitaire de Cardiologie et Results: The series were composed by 182 patients, with a mean age de Pneumologie de Québec, Université Laval, Québec city, QC, of 42.1±12.1 years and 70.3% female (128 cases). Preoperative Canada. weight and BMI were 106±17 Kg and 39.1±5.5 respectively. Surgical time was 135±28 min. In 67.3% of cases, laparoscopic approach was utilized. Hospital stay was 3.8±5.2 days. The 3.3% and 13.7%of Background: The weight loss effect of the duodeno-ileal switch patients required earlier or latter reoperations respectively. 12, 24, 36, component of a duodenal switch (DS) procedure in a series of 48 and 60-month BMI and %EWL were 27±4, 27±3, 28±2, 28±8, severely obese patients (pts) who had a duodeo-ileal switch (DIS) 23±9 and 69.6, 69.5, 64.7, 64.5, 69.4% respectively. Improvement of only as their sole bariatric procedure is described. comorbidities was observed in 89.5% of cases. General morbidity Methods: Our database of DS pts, prospectively kept since 1992, was was 21.4% (1.6% of medical etiology, 16.5% of surgical etiology and surveyed to identify pts who had a duodenal switch without the 3.3 of both groups). 12% of morbidity cases appeared as latter vertical gastrectomy component. Weight and BMI are reported as complications. Overall mortality was 1,6%. mean ± s.e. The t-test was used to compare continuous variables. Conclusion: SGEBP is an effective technique in terms of weight loss Results: Between January 2001 and April 2009, 49 consecutive and BMI reduction and improvement patients had a standalone duodeno-ileal switch without gastrectomy procedure. Our sample consists of 22 females and 27 males with a mean age of 58 years (range: 36-70)at the time of surgery. Initial O-035 Anti Diabetic Effect Of Laparoscopic Sleeve Gastrectomy weight and BMI were 143.9±3.6 Kg and 52.5±1.2 Kg/m2, With Duodenal Jejunal Bypass respectively. There was one perioperative mortality (< 30 days). Nadir weight and BMI were reached at an average of 1.8±0.2 years PRESENTER: Kazunori Kasama (Yotsuya Medical Cube) postoperatively and were 103.7±3.2 Kg and 38.0±1.2 Kg/m2 (n=48), respectively. The drop in BMI of 14.5±0.8 Kg/m2 was significant (p<0.001). Mean %EWL at nadir weight was 50.6±2.8%. Sleeve Co-Authors: Yosuke Seki1, Hideharu Shimizu1, Akiko Umezawa1 gastrectomy was then performed in 6 pts to complete the DS procedure at a mean of 22 months from the time of initial surgery. 1. Weight Loss Surgery, Yotsuya Medical Cube, Tokyo, Japan. Follow up for the duodeno-ileal switch only group ranges from 6 months to 8.3 years, and this group's weight related parameters over time are as follows: At 3 years, BMI= 37.4±1.3 Kg/m2 and Background: Laparoscopic Sleeve Gastrectomy (LSG) is thought be %EWL=48.8±3.7% (n=22); at 5 years, BMI= 39.2±2.5 Kg/m2 and one of good options as single procedure for Asian. Confining group %EWL=43.8±7.0% (n=9). to BMI less than 50, %EWL of LSG is almost same as LRYGB in Conclusion: Duodeno-ileal switch (DIS) alone is uncommonly Japanese series. But regarding anti-diabetic effect, cure rate after performed as a sole weight loss procedure; but in patients where LRYGB was better than that of LSG for Japanese. indications warrant foregoing the sleeve gastrectomy component, DIS We evaluated our initial series of Laparoscopic sleeve gastrectomy can be safely performed with good weight loss results. In this series, with duodenojejunal bypass (LSG/DJB) regarding anti-diabetic weight loss at 2 years and beyond compares well with other commonly performed bariatric operations. stage procedures. Results: 71 patients with BMI≥60 kg/m2 (median 65.7, range 60 – 95.7) and median age 45.6 (range 22 – 60) years underwent O-037 Beta Cell Function In Patients With T2DM After laparoscopic bariatric surgery during this period. Co-morbidities were Biliopancreatic Diversion (BPD). present in different combinations in 51 patients (72%). The median hospital stay was 3 (interquartile range 2 – 4) days and complications PRESENTER: Gianfranco Adami (University of Genova) occurred in 10 patients (12.9%). There was no mortality. 26 patients underwent a gastric bypass (RYGB) alone (Group A). Of the 45 patients who had a sleeve gastrectomy (SG), 18 underwent a Co-Authors: Flavia Carlini1, Gabriele D'alessandro1, Andrea duodenal switch and 4 had a re-SG at a median interval of 1.6 years Weiss1, Francesco Papadia1, Corrado Campisi1, Nicola Scopinaro1 (Group B). The outcomes in the first year for patients who had a SG and were awaiting the 2nd procedure were also compared (Group C). 1. Department of Surgery, University of Genova, Genova, Italy. (Table) Groups A and B, were similarly matched and outcomes were not significantly different. However, the weight loss at 1 year in Group A was significantly more than in the latter. (Table) Background: Beta cell function prior to and after BPD was evaluated Conclusion: Bariatric procedures in the super-super obese are equally by acute insulin response (AIR) to an EV glucose load (35g). safe and effective. Though the initial weight loss with RYGB is Methods: The study was carried out in morbidly obese (12 cases, more, the eventual weight loss achieved is similar in both groups. BMI >35), obese (13 cases, BMI 30-35), and overweight (10 cases, BMI< 30) T2DM patients. AIR was measured prior to BPD and at 1, 4 and 12 months following the operation. At 1 year, the T2DM was O- 039 Characteristics Of Body-Contouring Surgery Integrated considered resolved when fasting blood glucose (FBG) and HBA1c In A Bariatric Surgery Program were ≤125 mg/dl and 6%, respectively, on free diet and without anti- diabetic therapy. PRESENTER: Ludo Van Krunckelsven (Hospital Jan Yperman) Results: In morbidly obese T2DM patients AIR sharply increased by the 1 month and a further marked rise was found at 12 months (6.8, 25.1, 23.0 and 33.3 mcU/ml, pre-BPD and at 1,4 and 12 months, 1. Surgery, Hospital Jan Yperman, Ieper, Belgium. respectively) in the obese T2DM individuals a significant increase was observed at 4 and 12 months, (2.2, 5.7, 7.8 and 14.0 mcU/ml), while in the overweigh subjects a slight increase was recorded only at Background: The aim of the study was to evaluate reconstructive 12 months (2.1, 2.8, 2.3, 6.1 mcU/ml). The 12 months D2TM surgery integrated in a bariatric surgery department. resolution rate in morbidly obese, obese and overweight patients was Methods: Over a period of 15 years 3451 reconstructive procedures 90%, 38% and 20%, respectively. The 12 months T2DM resolution were performed on 2403 patients ( 16 to76 years old,65% female) : was independently predicted by the preoperative BMI and AIR different types of abdominoplasty-torsoplasty (80%), brachioplasty (r2=0.622), while T2DM duration, type and amount of therapy, and (6% ), preoperative FBG and HBA1c, were unrelated to the clinical outcome thighplasty (6%),mammoplasty (6%) and other ( 2%). Weight loss ( Conclusion: In T2DM morbidly obese patients AIR is promptly 15-180 kg ) was reached after sleeve gastrectomy,gastric restored and well maintained at long term after BPD, thus suggesting bypass,duodenal switch or Scopinaro biliopancreatic diversion. a preoperative beta cell deficit of low degree, and a key role of the Results: Reconstruction provides solutions for the functional,medical improvement in insulin secretion for the postoperative metabolic and aesthetic consequences of weight loss on body shape and is outcome. In T2DM patients with lower initial BMI, only a slight and started after stabilisation of weight loss ( 6-24 months delayed improvement of AIR was found, and this could explain the postoperatively). lower D2TM resolution rate. Nevertheless, the hypothesis that a 90% of our bariatric patients proceeded to reconstructive surgery, a further improvement of beta cell function might occur at longer term much higher figure than found in other reports ( mean of 15%). cannot be ruled out. The anticipation of reconstruction improves attitude towards the discomforts of changing body shape. Reconstruction itself improves mobility and body image,thus improving long term weight loss O-038 Bariatric Surgery In The Super-Super Obese – Single- results and prolonging patient satisfaction. An integrated approach Stage Versus Two-Stage Procedures. improves and prolongs general bariatric follow-up. There was no mortality. Early morbidity concerns seroma formation PRESENTER: Kesava Reddy Mannur (Homerton University and wound dehiscence. Late morbidity concerns hypertrophic Hospital NHS Foundation Trust) scarring and local hypoesthesia. Smoking is the only significant risk factor on early morbidity. The type of primary bariatric procedure does not influence outcome. Co-Authors: Samrat Mukherjee1, Harun Thomas1, Kalpana Conclusion: An integrated approach leads to easier access to Devalia1 reconstructive surgery and a higher % of patients proceeding to body- contouring, with better results of the total bariatric program. 1. Bariatric Surgery, Homerton University Hospital NHS Foundation Trust, London, United Kingdom. O-040 Safe Progression To And Performance Of Totally Robotic Roux-En-Y Gastric Bypass (RYGBP) Background: The treatment of the super-super obese (BMI≥60 Kg/m2) remains a challenge. We evaluate the outcomes following PRESENTER: Keith Kim (Florida Hospital Celebration Health) surgery in these patients and compare single-stage versus two-stage procedures. Methods: Super-super obese patients undergoing bariatric procedures Co Authors: Arundathi Rao1, Eduardo Parra-Davila1, Cynthia K. (July 2005--June 2009) were extracted from our database. Patient Buffington1 parameters were analysed along with the surgical outcomes. The results were compared in those undergoing a two-stage versus single- 1. Metabolic Medicine and Surgery Institute, Florida Hospital Celebration Health, Celebration, FL, United States. hernia respectively. No BPD/DS related reoperation or mortality occurred in this series. Conclusion: Robotically assisted laparoscopic BPD/DS is a safe and Background: Although surgery risks and complications are low with feasible alternative for weight loss surgery. Improved ease of robotic technology, the adoption of robotic surgery in bariatrics has operation, visualization, and range of motion especially during been slow. In this study, we: 1) describe a safe, stepwise procedure creation of anastomosis are the advantages of this technique. for progression from laparoscopic to totally robotic Roux-en-Y gastric bypass (RYGBP) and 2) report early and late experiences with our totally robotic RYGBP series. O-042 The Learning Curve For Laparoscopic Robot-Assisted Methods: The performance of a totally robotic RYGBP from Duodenal Switch: Factors Influencing Operative Times laparoscopic surgery was performed by a single surgeon using a stepwise procedure that included 3 progressive stages: 1) robotic PRESENTER: Ranjan Sudan (Duke University Medical Center) construction of the gastrojejunostomy, 2) the jejunojejunostomy, and 3) the totally robotic procedure. In the transition from stage 1 to stage 2, the jejunojejunostomy was added after the gastrojejunostomy Co-Authors: Kyla Bennett1, Alene Wright2, Sandra Stinette1, Debra could be performed in 30 minutes or less. As proficiency increased, Sudan1 we progressed cautiously to the next stage. Results: A total of 26 gastrojejunal anastomosis and 4 gastrojejunal anastomosis+jejunojejunal anastomosis were performed prior to 1. Duke University Medical Center, Durham, NC, United States. proceeding to a totally robotic procedure. In the early (1-10) versus 2. Creighton University Medical Center, Omaha, NE, United States. late (82-92) series of totally robotic procedures, operative times (OT) averaged 183.5 and 128.4 min, respectively (p=0.005), the ratio of Background: The laparoscopic duodenal switch procedure is a OT to BMI was a respective 3.8 and 2.3 (p=0.0002), docking times complex procedure and, to our knowledge, no data regarding its were 8.0 vs. 3.4 min (p=0.0008), and console times averaged 137.0 learning curve exists in the current literature. vs. 87.6 (p<0.0001) min. Of the 92 totally robotic procedures, there Methods: To determine the threshold number of cases to decrease have been no mortalities, no leaks, no blood transfusions nor re- operative times and patient complications, data from a single operations specific to the surgery. surgeon‟s initial 120 robot-assisted LDS were analyzed. Conclusion: Totally robotic RYGBP can be safely approached The operative time of LDS as a function of case number was through systematic stepwise progression. The procedure has few analyzed with linear regression. It was then analyzed with complications and, with surgeon experience, low operative times. multivariate linear regression to determine the modifying effects of patient factors on the learning curve. The learning curve was also O-041 Robotically Assisted Laparoscopic Biliopancreatic analyzed in terms of a composite outcome (leak, conversion and Diversion With Duodenal Switch. Initial Experience Of 42 Cases significant bleeding - defined as mean blood loss + 1SD) using both logistic regression and risk-adjusted CUSUM (RA-CUSUM). Results: Operative time decreased with each successive case by an PRESENTER: Gintaras. Antanavicius (Abington Memorial average of three minutes (p<0.001, R2=0.63). Independent risk Hospital) factors for prolonged operative time were adhesiolysis and bleeding. Rates of conversion, leak and significant bleeding were 2.2%, 5.8% and 13.3%, respectively. Complications declined significantly after Co-Author: Iswanto Sucandy2 the first chronologic quartile, while length of stay continued to decline until the third quartile. The 30 day readmission rate declined 1. Institute for Metabolic and Bariatric Surgery, Abington Memorial after the second quartile. In the RA-CUSUM analysis, factors Hospital, Philadelphia, PA, United States. retained in the best fit model for composite outcome were male 2. General Surgery, Abington Memorial Hospital, Philadelphia, PA, gender, BMI and case number. Patient complications stabilized after United States. 40 cases and reduced after 55 cases. Conclusion: Threshold to safely perform the laparoscopic robot assisted duodenal switch with relatively low morbidity appears to be Background: Biliopancreatic diversion with duodenal switch about 55 cases however operative times continue to decrease (BPD/DS) is considered the most effective surgical option for throughout the experience. morbidly obese patients. Numerous techniques have been described – open, laparoscopic, combination of open and laparoscopic, as well as robotically assisted. We describe our early experience of 42 O-043 Day Mortality In The Longitudinal Assessment Of robotically assisted laparoscopic BPD/DS and its feasibility as an Bariatric Surgery. alternative for treatment of morbid obesity. Methods: A retrospective review of a prospectively maintained PRESENTER: Mark Smith (Oregon Weight Loss Surgery) database was conducted in all patients undergoing BPD/DS between December 2008 and February 2010. Outcomes and perioperative complications as well as advantage of robotically assisted approach Co-Authors: Emma Patterson1, Anita Courcoulas4, Gregory Dakin8, were recorded and analyzed. David Flum2, Laura Machado9, James E. Mitchell7, John Pender5, Results: A total of 42 consecutive patients (F:M=30:12) were Alfons Pomp8, Walter J. Pories5, Ramesh C. Ramanathan4, Beth included in this study. Average age was 43.4 (20-60), BMI 50.2 (37- Schrope6, Aku Ude6, Bruce M. Wolfe3 70) and number of preoperative comorbidities 6.2 (3-10). Mean operative time was 322 (262-603 ) minutes without open conversion. There were no intraoperative or 30 day major postoperative 1. Oregon Weight Loss Surgery, Portland, OR, United States. complications (ie; anastomotic leak, hemorrhage, intraabdominal 2. University of Washington, Seattle, WA, United States. organ injury, and thromboembolic events) seen. A single patient 3. Oregon Health and Science University, Portland, OR, United experienced port site infection and another developed severe carpal States. tunnel syndrome exacerbation postoperatively. Average length of 4. University of Pittsburgh, Pittsburgh, PA, United States. hospital stay was 3.4 (3-13) days. Two patients were readmitted 5. East Carolina University, Greenville, NC, United States. within 30 days due to fluid retention and incarcerated umbilical 6. Columbia University Medical Center, New York, NY, United States. O-045 Surgical Morbidity Following Laparoscopic Adjustable 7. Neuropsychiatric Research Institute, Fargo, ND, United States. Gastric Banding, Laparoscopic Sleeve Gastrectomy And 8. Weill Cornell Medical College, New York, NY, United States. Laparoscopic Roux-En-Y Gastric Bypass. 9. UC Davis Medical Center, Sacremento, CA, United States. PRESENTER: Catherine Bradshaw (Imperial College Background: LABS-1 is a 10-center, prospective study examining Healthcare) 30-day outcomes following bariatric surgery. Methods: Causes of death were evaluated by the LABS adjudication committee, comprised of LABS surgeons and scientists reviewing Co-Authors: Sherif Hakky1, William Collins1, Ahmed R. Ahmed1 clinical, not administrative, information. Results: 4776 patients underwent primary bariatric procedures in 1. Imperial College Healthcare, London, United Kingdom. LABS-1: 3412 patients had RYGB; 1198 patients had LAGB; and 166 patients underwent other procedures and were excluded from the analysis. Of these 4610 patients, 15 (0.3%) died within 30-days after Background: Bariatric surgery is currently the most effective method RYGB (median survival 12 days since surgery; range 2-30 days). The of achieving long-term weight loss in the morbidly obese population, 15 mortalities had a median age of 46 years (range 30-61), median but the optimal methods are uncertain. We compared surgical BMI of 57.4 kg/m2 (range 42.8-89.9 kg/m2) and 40% were male. morbidity following laparoscopic adjustable gastric banding (LAGB), There were no deaths after LAGB. One death occurred within 48- laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y hours due to loss of airway. Five patients died of sepsis; four of these gastric bypass (LRYGB). from anastomotic leak. Four patients died of cardiac causes: two Methods: Retrospective study of 407 patients undergoing bariatric myocardial infarctions; one heart failure; and one arrhythmia. Two surgery from December 2007 to January 2010 in a UK Bariatric deaths were due to pulmonary embolism (PE), and one patient died Surgery Centre of Excellence. Outcomes included mortality, from aspiration pneumonia. Cause of death could not be determined complications and re-operation or revisional procedures. for two patients during adjudication. Results: Outcomes were examined from 220 LRYGBs, 100 LSGs Conclusion: Overall 30-day mortality was 0.3%. Anastomotic leak, and 87 LAGBs. There totalled 1 death, which was in the LRYGB cardiac events, and PE were the leading causes. Despite the large group (0.5%). 7 patients in the LAGB group (8.0%) required a sample size, the number of deaths was too small for meaningful second bariatric procedure to achieve the desired weight loss: 5 statistical analysis of predictive factors. underwent LRYGB, 2 underwent LSG. 1 patient in the LSG group (1.0%) needed a second procedure to achieve further weight loss. Overall complication rates were not significantly different between O-044 Relevance Of The Obesity Surgery Mortality Risk Score the 3 operations: 12.7% in the LRYGB group, 18% in the LSG In Patients Undergoing Roux-En-Y Gastric Bypass. A Study In group, 10.3% in the LAGB group. Though re-operations rates were The United Kingdom. similar (8-9%) in all groups, the patterns observed varied significantly. It also was noted that a sub-group of patients (2.3%) PRESENTER: Sami Mansour (St George's Healthcare NHS suffered from long-term chronic abdominal pain post-gastric bypass Trust) and required multiple further operations. Conclusion: Laparoscopic bariatric surgery is now performed with acceptable morbidity and mortality, and outcomes of LSG are Co-Authors: Vasha Kaur1, Georgios Vasilikostas1, Marcus Reddy1, comparable to the more widely practised LRYGB. However, Andrew Wan1 different patterns of complications and degrees of weight loss illustrate the importance of tailoring the choice of operation to the individual. 1. Bariatric Surgery, St George's Healthcare NHS Trust, London, United Kingdom. Summary of overall complication rate for all patients Background: The Obesity Surgery Mortality Risk Score (OS-MRS) has been proposed as a user-friendly tool for the assessment and risk LAGB LSG LRYGB stratification of patients undergoing Bariatric surgery. We assessed patients patients patients the relevance of the OS-MRS in our study. n = 87 n = 100 n = 220 Methods: Prospectively collected data from 116 patients undergoing (%) (%) (%) Laparoscopic Roux-en-Y Gastric Bypass (RYGBP) at a single Overall complication university hospital over a period of 18 months from 2008 to 2009 10.3 18 12.7 were analyzed to determine the preoperative factors correlating with rate 90-day mortality.

Results: The variables used include body mass index ≥50 kg/m2, male gender, hypertension, patient age ≥45 years and pulmonary embolus risk, which included previous thrombosis, pulmonary O-046 Letting Our Definitions Slip. Are We Reporting Different embolus, inferior vena cava filter and right heart failure. Using the 3 Outcomes? risk classes (A, B and C), 97 % of the patients were among the low and intermediate risk groups (A and B). There were zero mortality PRESENTER: Sally Norton ( Southmead Hospital) rates in our study group. Conclusion: The analysis confirms that mortality risk for gastric bypass can be stratified based upon independent variables that can be Co-Authors: Simon Monkhouse2, Sharon Bates1, Justin Morgan1 identified before surgery. The OS-MRS is a clinically relevant scoring system and may contribute to surgical decision making in 1. Department of Surgery, Southmead Hospital, Bristol, United bariatric surgery. Kingdom. 2. Surgery, Gloucester Royal Hospital, Gloucester, United Kingdom. Background: Laparoscopic adjustable gastric banding is a popular A Diagnostic Dilemma With Potential Devastating Consequences; bariatric procedure but may be complicated by slippage and pouch Can We Decrease The Incidence? dilatation. There is no universal standard for reporting of these complications and consequently, there is huge variability in PRESENTER: Minhao Zhou (UMass Memorial) semantics and complication subtypes. This makes comparison of studies difficult. Complication rates are hugely varied which cannot simply be accounted for by surgeon, patient or technical factors. The Co-Authors: John J. Kelly1, Donald Czerniach1, Richard Perugini1, aim of this study was to identify the variability in reporting of Philip Cohen1, Karen Gallagher-Dorval1 slippage and pouch dilation. Methods: A full literature search was performed using the Medline, Embase and Cochrane Central Register of Controlled Trials 1. Surgery, UMass Memorial, Worcester, MA, United States. electronic databases. 28 studies were selected for inclusion according to a minimum follow-up of 12 months. These were analysed and Background: Small bowl obstruction due to internal hernia is a reporting of complications was recorded. known complication after roux-en-y gastric bypass. When this Results: Reported complication rates varied from 0.26% to 63.4%. As presents during pregnancy, it can be a diagnostic dilemma due to its well as differing surgical techniques there was a wide variability in nonspecific clinical presentation, the extended differential diagnosis mode of reporting of complications. Only 18% of studies correctly of abdominal pain in the pregnant patient , the lack of familiarity to defined anterior slippage, posterior slippage and pouch dilatation as the non-bariatric caregiver, and reluctance to use traditional three distinct entities with several other synonymous terms used. radiologic studies in the gravid patient. Mode of follow-up varied considerably with 32% using clinical Methods: Single institution experience with internal hernia in the follow-up and 21% using radiological follow-up. 50% of studies did gravid patient. Literature review of internal hernias during pregnancy not specify completeness of follow-up. in post gastric bypass patients. A review of our practice in closing all Conclusion: Variability in complication rate is attributed to various internal hernia defects at the time of laparoscopic roux-en-y gastric factors. Length of follow- up, follow-up regime and how bypass. complications are defined, all influence the reported outcome. Results: Two gravid patients with internal hernia were encountered. Accurate, clear definitions are vital for comparison between groups in One was operated on laparoscopically and mother and fetus order to improve outcomes for patients. recovered without sequelae. The other had emergent open operation and cesarean section. Mother had a prolonged recovery and the fetus did not survive. There has been 17 reported cases in the literature of O-047 Coronary Flow Reserve (CFR) In Obese Patients: New internal hernia during pregnancy after gastric bypass. Outcomes have Hints Between Inflammation And Cardiovascular Risk. ranged from uneventful laparoscopic repair of internal hernia to emergent exploratory laparotomy with maternal and fetal death. The PRESENTER: Mirto Foletto (Bariatric Unit - Padua University incidence of internal hernia at our institution prior to routine closure Hospital) of mesenteric defects was 3.62%. This was decreased to 0.85% with routine mesenteric defect closure.

Co-Authors: Roberto Serra1, Roberto Vettor1, Francesco Tona1, Conclusion: The incidence of internal hernias will rise as bariatric Luca Prevedello1, Alessandro Scarda1 surgery becomes more prevalent. Routine closure of mesenteric defects can decrease this incidence. When internal hernia is encountered in a gravid patient, prompt diagnosis and early 1. Bariatric Unit - Padua University Hospital, Padua, Italy. involvement of a bariatric surgeon is crucial in avoiding potential devastating consequences. Background: Fat mass distribution seems to play a key-role as far as obesity-related comorbidities. Epicardic adipose tissue seems to be O-049 Petersen Hernia Following Laparoscopic Gastric Bypass- the major determnant of cardiac complications. Case Report, Diagnostic Sign And Proposed Classification Methods: To identify a possible cardiac microcirculatory disfunction System in obese and overweight people with negative history cardiac disease, coronary flow reserve (CFR) was assessed with cardiac US scan and compared with a matched group of non obese patients. PRESENTER: Conor Magee (Gravitas Centre for Bariatric Results: Forty-one obese and forty non obese patients were tested. Surgery) Impaired CFR (cut-off < 2.5) was found in 88% of obese patients, while only 12% had pathological results within the control group. Among the obese group, significant differences resulted between Co-Authors: Jayne M. Brocklehurst1, Simon Weaver1, Robert patients with normal or impaired CFR in terms of age (40.3±14.5 vs Macadam1, Shafiq Javed1, David Kerrigan1 48.4±11.2 years, p < 0.05), BMI (38.39±5.1 vs 46.3±10.2, p <0.002), fatty mass (43.8±13.1 vs 57.3±19.9 kg, p < 0.01) and rectum-aortic 1. Gravitas Centre for Bariatric Surgery, Liverpool, 0, United distance (59.3±7 vs 95.2±31.7 mm. P<0.01). Kingdom. CFR showed a positive correlation with BMI (p <0.006), age (p <0.087), diastolic dysfunction (p <0.038), TNF-alpha (p<0.019) and IL-6 (p<0.004). These latter parameter were independent factors for Background: The following atypical case report highlights the need impaired CFR. for a classification of Petersen‟s herniae. Conclusion: Our data showed that visceral obesity may impair CFR Methods: A 42 year-old woman presented 18 months following leading to a pre-clinic phase of ischemic cardiac disease through LRYGB with vomiting of undigested food and abdominal pain. chronic inflammatory processes elicited by adipocytokines. Although imaging was inconclusive, she was initially treated as adhesional pain by a non-bariatric surgeon. After review by a bariatric surgeon (who noted a foetor suggestive of infarcted bowel) an urgent laparotomy detected a strangulated Petersen hernia O-048 Internal Hernia During Pregnancy After Gastric Bypass, containing 15cm of alimentary limb. This responded to release and warm packs without resort to resection. Petersen‟s space was then closed. Silva2, Mário Reginato Bettinelli2 Results: Petersen‟s hernia requires a high index of diagnostic suspicion. Typically, the biliopancreatic (BP) limb is obstructed with 1. Treatment Center for Morbid Obesity (CITOM), Porto Alegre - an absence of vomiting, although our case report underlines the RS, Brazil. potential for diagnostic confusion when obstruction of the alimentary 2. Universidade Luterana do Brasil (ULBRA), Porto Alegre, Brazil. limb leads to vomiting as a prominent symptom. Imaging can be inconclusive and vomiting could lead to false diagnoses such as adhesions. The distinctive foetor in this case (due to the short Background: Objective: To study the complications encountered distance between the strangulated bowel and oral cavity) helped to during the learning curve of Roux-en-Y Gastric Bypass (RYGB), and alert us to the correct diagnosis. the implications of those complications and how were they managed. Conclusion: We propose sub-classifiying Petersen Hernia as type A (Alimentary limb involved), type B (Bilio-pancreatic limb involved) Methods: Methods: This study was designed in historical cohort and type C (common channel or other viscera). This system may study with retrospective data of patients operated by the same improve audit and outcomes of this potentially fatal condition. surgeon of CITOM between 2001 and 2009. Results: Results: During the first nine years of experience of CITOM, were performed 1181 RYGB. It was observed an occurrence of 83 O-050 Bowel Obstruction In Bariatric Surgery: Experience In complications in 75 patients, resulting in a 7.02% rate of 500 Patients After Roux-En-Y Gastric Bypass. postoperative complications. In the first years there were 24.2% rate of complications and in last years occurred only 4.07% of complications. There were 12 different types of complications related PRESENTER: Roberto Rumbaut (Hospital San Jose-TEC de to this method, and the most frequent were gastrojejunal stenosis Monterrey) (2.45%), fistula (2.03%) and intra-abdominal abscess (0.76%). Complications were managed clinically in 30% cases, endoscopically in 35% cases and surgically in 35% cases. There was a mortality rate Co-Authors: Rodrigo Merino1, Horacio Guajardo1, Santiago of 0.42% in this population, and 80% of the deaths happened in Sherwell2 patients with super-obesity classification. The major causes of death were intra-abdominal abscesses (40%) and pulmonary 1. Bariatric Surgery, Hospital San Jose-TEC de Monterrey, thromboembolism (40%). Monterrey, Nuevo León, Mexico. Conclusion: Conclusion: It can be concluded that the number of 2. General Surgery, Hospital San Jose-TEC de Monterrey, complications decreased through the learning curve as the experience Monterrey, Nuevo León, Mexico. of the team increased. Strictures and fistulas remained the most frequent complications over the years, being the first resolucionated by endoscopic treatment, and the second by clinical treatment when Background: Bowel obstruction is one of the most common drainaged to the exterior of the abdominal cavity and through a complications of Laparoscopic Roux-en-Y gastric bypass (LRYGB). second operation when leakaged into the abdominal cavity. The rate The main cause of intestinal occlusion secondary to gastric bypass is of complications related to this method can be considered low. The the internal hernia, occurring more frequently in the mesenteric incidence of mortality is also very small, and can be related to defect produced in the distal anastomosis. The stricture of the distal patients with higher BMI values. small bowel anastomosis is the third cause of intestinal occlusion reported in 0.5% of the patients. Aim: Report the incidence of bowel obstruction in patients with gastric bypass in this center. O-052 Gastro-Jejunostomy Stenosis On Roux-And-Y Gastric Methods: We retrospectively reviewed 492 cases of patients in whom Bypass. Changing The Suture Reduces The Incidence. an antecolic antegastric LRYGB, with closure of mesenteric defects, was performed since January of 2004 to December 2009. Results: Seven (1.42%) of the 492 patients developed bowel PRESENTER: Manoel Galvao Neto (Gastro Obeso Center) obstruction due to internal hernia, while six (0.86%) patients was secondary to stricture in the jejujojejunostomy. The sites where the internal hernias occurred were the mesenteric defect in 72% (5) of the Co-Authors: Almino C. Ramos1, Manoela Galvao1, Andrey Carlo1, patients, the Petersen space in 14% (1) and in the transmesocolic Edwin Canseco1, Thales D. Galvao1, Luis F. Evangelista2, Marcelo space in 14% (1). All the patients required surgical treatment. Four Falcao2, Josemberg M. Campos2 patients with obstruction at the jejunojejunostomy was due to torsion of the anastomosis (66%), one due to swelling of the anastomosis 1. Surgery, Gastro Obeso Center, Sao Paulo, Sao Paulo, Brazil. (17%) and one more secondary to haemobezoar (17%). All of them 2. Surgery, Federal University of Pernambuco, Recife, Pernambuco, improved with medical treatment. Brazil. Conclusion: We found an incidence of internal hernia in patients with gastric bypass of 1.42% compared with the 3.3% described in the literature. We found that, even the obstruction at the distal Background: One of the major complications after RYGB is the anastomosis is not a common complication, all the patients improved gastro-jejunostomy (G-J) stenosis. Among possible variables on this with medical management. complication is the type of suture used. The authors present a series with the incidence of G-J stenosis at lap RYGB patients using 2 types of suture on G-J closure in a standard fashion O-051 Dealing With Complications Of Gastric Bypass In Y-De- Methods: From a 4521 lap RYBG patients series performed in- Roux: Our Experience In The First 9 Years. between December of 2001 to December of 2008, 194 (4,3%) patients with G-J stenosis endoscopic dilated with TTS balloons up to 12mm were identified over retrospective charts review. All patients PRESENTER: Renato Souza da Silva (Treatment Center for were operated with a standard lap RYGB with a G-J constructed with Morbid Obesity (CITOM) ) linear stapler, calibrated with a 32fr bougie and closed with one layer running suture. No statistical differences were observed among gender, age or BMI. From 2001 to 2004 the suture used on G-J was a Co-Authros: Renata Carvalho da Silva2, Ana Paula Carvalho da non-absorbable braided (Ethibond®) and from 2005 to 2008 an 59.5±30.4 1 y* 97.3±29.5 (19) 0.002 absorbable monofilament (PDS®). Statistical analyzes were (10) performed over yearly adjusted stenosis rates Fat Mass reduction(6 m), Results: When using the non-absorbable suture the yearly-adjusted 8.2%±5.0 13.0±4.0 0.001 rates were 3.77(2001), 3.01 (2002), 5.54 (2003) and 8.26% (2004) % † respectively . Using the absorbable suture, the yearly-adjusted rates All values but gender are mean ± SD. † t-test for independent were 2.68 (2005), 2.16 (2006), 1.6 (2007) and 1.42% (2008). The variables, * Mann Withney Wilcoxon reduction of stenosis rates was significant (P<0.05) on the single variable change over a standard lap RYGB technique Conclusion: The use of a specific absorbable suture reduces the O-054 Comparison Of Hand-Sewn, Linear Stapled And Circular incidence of stenosis at linear stapled calibrated G-J on lap RYGB Stapled Gastrojejunostomy In Laparoscopic Roux-En-Y Gastric Bypass

PRESENTER: Franklin Bendewald (Indiana University School of Medicine)

Co- Authors: Jennifer Choi1, Lorie Blythe1, John Ditslear1, Don J. Selzer1, Samer Mattar1

1. Surgery, Indiana University School of Medicine, Indianapolis, IN,

United States.

Background: There is no consensus on the ideal gastrojejunostomy technique in laparoscopic roux-en-Y gastric bypass (LRYGB). We O-053 Laparoscopic Roux-En-Y Gastric Bypass (LRYGB) Vs. reviewed our experience with three gastrojejunostomy techniques New Direction Dietary Program (ND) In Grade 1 & 2 Obesity (hand-sewn, linear stapled, and 25-mm circular stapled) to determine which anastomosis technique is associated with the least early PRESENTER: Miguel Herrera (ABC Medical Center) complications. Methods: In an academic center, 835 consecutive patients underwent LRYGB using three techniques by three surgeons: hand-sewn (HSA), Co-Authors: Hugo Sanchez1, Joaquin Joya1, Rocio Duran1, Vianey linear stapled (LSA) and circular stapled(CSA). These operations Anduaga1, Maureen Mosti1 were performed from November 2004 through December 2009. All patients had a minimum of 2 months follow up. Early post-operative gastrojejunostomy leak, stricture, and marginal ulcer formation were 1. Obesity Clinic, ABC Medical Center, Mexico DF, Distrito Federal, identified and classified according to surgical technique. Multivariate Mexico. analysis was performed to determine associations between complications and anastomosis technique. Results: Preoperative BMI and comorbidities did not differ between Background: Indications for bariatric surgery established by the NIH the three groups. The predominant number of patients underwent have been widely accepted. Management of patients with lesser LSA (n=514) vs HSA (n=180) or CSA (n=140). Upon evaluation by degree of obesity includes several programs such as ND which is multivariate analysis, there was no statistical significance in the rate based on meal replacements. The aim was to analyze 2 cohorts with of leak (LSA 1.0%, HAS 1.1%, CSA 0.0%, p=0.480), stricture (LSA BMI between 32 and 39 Kg/m2 and no comorbidities treated by 6.0%, HAS 6.1%, CSA 4.3%, p=0.657), or marginal ulcer (LSA either LRYGB or ND. 8.0%, HAS 7.7%, CSA 3.6%, p=0.180). Methods: From 2006 to 2009, 20 patients underwent LRYGB and 37 Conclusion: The three techniques can be used safely with a low were treated with ND. Weight loss and complications were complication rate. Our data did not identify a superior anastomotic comparatively analyzed. technique. Results: Both groups were comparable. There was no surgical morbidity/mortality. Four surgical patients developed complications in the long term: Results are as follows. O-055 Prospective Randomized Double Blind Comparative Study Conclusion: Weight loss of both groups was equivalent up to 6 Between Silicone Ring And Prolene Mesh For Improving Gastric months. It was superior in the surgical group at 1 year, since many Restriction In Vertical Gastroplasty With Bypass. patients withdrew ND. Complications after LRYGB may occur. PRESENTER: Fernando Barroso (Instituto F.L. Barroso)

ND (n=37) LRYGBP(n=20) P Co-Authors: Marcello P. Rodrigues2, Marco Antonio Leite3, Licia P. Mean age, years† 40.3±10 35.0±12.5 0.70 Pereira4, Thais Branquinho5 Female/Male, n* 32/5 118/2 0.20 1. Instituto F.L. Barroso, Rio de Janeiro, Rio de Janeiro, Brazil. Initial BMI, Kg/m2† 36.3±3.5 36.9±1.7 0.053 2. Instituto F.L.Barroso, Rio de Janeiro, Rio de Janeiro, Brazil. EBWL, % 3. Instituto F.L. Barroso, Rio de Janeiro, Rio de Janeiro, Brazil. 51.4±12.6 4. Instituto F.L. Barroso, Rio de Janeiro, Rio de Janeiro, Brazil. 3 m† 57.5±11.5 (18) 0.80 (37) 5. Instituto F.L. Barroso, Rio de Janeiro, Rio de Janeiro, Brazil.

60.3±24.9 6 m† 77.0±15.8 (16) 0.61 Background: Aiming to obtain a lasting gastric restriction in the (37) gastroplasty with bypass, surgeons often use an annular device above the gastrojejunal anastomosis. The device of choice tends to be either PRESENTER: Jens Larsen (Private Hospital Molholm) a silicone ring or a prolene mesh, with each alternative having its supporters. We studied comparatively the patient tolerance to gastric Co-Authors: Uffe Raundahl1, Thorbjørn Sommer1, Jens Peter restriction, excess weight loss, and complications Kroustrup1

Methods: Between February 2006 and February 2007, 235 patients 1. Bariatic Surgery, Private Hospital Molholm, Vejle, Denmark. that underwent a vertical gastroplasty with a proximal bypass operation were randomized to have a silicone ring (group A - 129) or Background: Denmark has a socialized health –care system, 99% of a prolene mesh (group B - 106), using a tube 32fr, for calibration. the patients are treated by the public hospitals. However, so far the The tolerance to gastric restriction, measured by the frequency of five public University centres have not been able to cover the vomiting, and the EWL% were evaluated by a nutritionist unaware of growing demand, and 85% of the bariatric procedures are now the device used. We followed personally 215 patients for 1 year, 185 performed by private hospitals. During 2009 the Private Hospital for 2 years and 64 for 3 or more years. Molholm performed 900 of total 3000 procedures performed in Results: The tolerance to gastro restriction and the excess weight loss Denmark. The goal has been to organize a cost effective program were not significantly different using either device, in the period with low morbidity and mortality by introducing the fast track studied. As complications we observed four stenosis caused by the surgery. Aim of the study was to evaluate time of discharge, patient silicone ring and two stenosis caused by the prolene mesh. We easily satisfaction, perioperative morbidity and mortality. removed 3 rings after failure of endoscopic dilatation. The stenosis Methods: Consecutive prospective study of 2000 fast track one with prolene mesh responded well to endoscopic dilatation surgeon laparoscopic gastric bypass procedures. Conclusion: As far as the tolerance to gastro restriction, %EWL, and Results: In the period the first of July 2007 to the first of February complications are concerned, at three years follow-up, no significant 2010, 2000 laparoscopic gastric bypass operations was performed. difference was registered. The median age was 39 years, female/male ratio 81/19. The median In case of complications with the ring the removal represented an operative time was 54 minutes (range 28-300). The median time of ease task. discharge after operation was 22 hours. In-hospital complications 2.6 % of which 0,9% required re-operation. The patient assessments of O-056 Roux En Y Gastric Bypass (RYGB) By Single Incision time of discharge, 89 % patients were very satisfied, 10 % satisfied, Mini-Laparotomy: Outcomes In 3300 Consecutive Patients and 2% unsatisfied. The re-admission rate within 30 days was 5 % of which 1.9 % required re-operation, 1 % caused by leakage. The PRESENTER: Joseph Caruana (Sisters of Charity Hospital and mortality rate within 30 days was 0.1%. State University of New York at Buffalo) Conclusion: Fast track laparoscopic gastric bypass is a cost-effective procedure, with high patient satisfaction, low morbidity and Co-Authors: Marc N. McCabe1, Audrey D. Smith2, Julia M. mortality. Kabakov2

1. Surgery, Sisters of Charity Hospital and State University of New O-058 The Search For Factors That Might Influence Weight Loss York at Buffalo, Buffalo, NY, United States. After LRYGB: Impaired Glucose Metabolism. 2. , Synergy Bariatrics, Buffalo, NY, United States. PRESENTER: Gil Faria (Hospital Sao Joao) Background: Although laparoscopic Roux en Y gastric bypass Co-Authors: John R. Preto1, Antonio Gouveia1, Jose Barbosa2, (LRYGB) has popularized this weight loss procedure, the costs are Silvestre Carneiro2, Eduardo L. Costa1, Cristina Teixeira1, Cidalia justifiable if outcomes are superior to the open technique. We report 1 1 1 Gil , Joaquim Sousa-Rodrigues , Joaquim Oliveira Alves here our results with single incision mini-laparotomy. Methods: From June 2000 through November 2009, we (JAC and MNM) performed 3300 RYGB using a 10-15 cm single abdominal 1. Unidade Tratamento Cirúrgico de Obesidade - Serviço de Cirurgia incision. Protocols were developed for patient selection and Geral, Hospital Sao Joao, Porto, Portugal. education, and for the prevention of perioperative complications. 2. Cirurgia Geral, Faculdade de Medicina do Porto, Porto, 0, Patients were retrospectively assigned an Obesity Surgery Mortality Portugal. Risk Score (OS-MRS) (Demaria EJ, et al Surg Obes Relat Dis. 2007;3:34-40). A 100 patient subset of these was compared with 100 Background: Obesity is a major risk factor for Diabettes Mellitus consecutive patients having LRYGB by another surgeon at our type 2 (T2DM) and obesity surgery has been reported as the most institution for hospital costs and length of stay (LOS). effective treatment for obesity-related T2DM. Some reports suggest Results: 84% were females with a mean BMI of 50.2 ± 8.6. BMI of that insulin-resistance might be related to less weight loss after males was 54.1 ± 9.7. There were 1793 Class A, 1288 Class B, and obesity surgery. 219 Class C patients. Eleven patients (0.3%) died within 90 days (1 Methods: Retrospective analysis of the clinical records of 47 Class A, 7 Class B, and 3 Class C), with mortality rates in all classes consectuive patients with more than 6 months of follow-up. We less than expected by the OS-MRS. Complications included bleeding stratified the patients according to their clinical state of glucose (1.4 %), leak (1 %), pulmonary embolism (0.7 %), internal hernia metabolism: Group A – normal; Group B – glucose metabolism (1.5%), and incisional hernia (5.6%). LOS (2.7 days) was similar to impairment (GMI); Group C – T2DM. that in the LRYGB patients (2.5 days), while typical operating room Results: The mean pre-op weight was 121,7kg (mean BMI of charges ($2000 versus $6900) were less. 45,9kg/m^2). Fifty-six percent of the patients had normal glucose Conclusion: Our protocols and operative technique should be metabolism, 27% had GMI and 17% had T2DM. Age, initial weight reproducible in other centers and may have special appeal in and BMI were not different between groups. countries where the costs of LRYGB limit its application to qualified At 12 months, the rate of “cure” from obesity (BMI<30) was 78%, patients 40% and 0%, respectively for Groups A, B and C (p=0,006). At 6 months, the % of excess BMI lost (%EBL) was 63%, 64% and 50% (p=0,17). At 12 months, the %EBL was respectively 84%, 75% and O-057 2000 Fast Track Laparoscopic Bypass Procedures 58% (p=0,02). The average total weight lost was 45kg, 47kg and 30kg at 12 months, for groups A, B and C (p=0,014); and the average BMI was 28, 30 and 34 (p=0,05). experienced laparoscopic surgeon (LA) and the last 49 cases done by Conclusion: Diabetic patients lost significantly less weight and an experienced bariatric surgeon (KM) who has performed more than %EBL at 12 months. Normal patients had the best overall results with 700 cases. Data collected included Body Mass Index (BMI), ~80% achieving a BMI<30kg/m^2 at 1 year post-op and a mean BMI operative time, perioperative complication. of 28kg/m^2. Results: LA‟ first 30 RYGB cases- Mean operative time (min) 202.1 Although T2DM patients are the ones who loose less weight, their (range 126 – 307), next 19 cases mean operative time (min) 173.68 overall results are satisfying (58% EBL at 1 year) and their are those (range 120 – 268). The overall operative time for the first 49 cases who may benefit the most from reduction in morbidity and mortality. was 191.08 minutes (range 120 - 307) .The mean BMI was 45.4 However, should these results be confirmed, it might help to establish (range 36 - 51.4). 8 peri-operative complications were experienced, 2 more realistic goals in terms of weight loose. cases of anastomosis of biliary limb to the gastric pouch, 4 cases of anastomotic leak, 1 case of port site bleed and 1 liver abscess. Surgeon KM Last 50 cases- Mean BMI 44.5 (35- to 70), mean O-059 Eliminating Learning Curve Related Morbidity Using A operative time (min) 67 (range 45 - 90). No intra-operative Structured Fellowship Programme In Gastric Bypass Surgery. complications and 1 post-operative case of port site bleeding, that settled with conservative management. PRESENTER: Thorbjorn Sommer (Moelholm Private Hospital) Conclusion: RYGB is technically demanding procedure and in spite of extensive laparoscopic experience the operative time and Co-Author :Jens F. Larsen1 complications are significantly more in the initial cases. Continuing mentoring in the early cases my help reduce complications

1. Surgery, Moelholm Private Hospital, Vejle, Denmark. O-061 Psychosocial Profile Of Morbidly Obese Patients Background: Laparoscopic gastric bypass is associated with a Undergoing Gastric Bypass significant learning curve,and a systematic training programme is needed to decrease morbidity from learning the procedure. Methods: Training a new bariatric surgeon with no former bariatric PRESENTER: Mariemma Antor (Universidad Central de experience was done using a structured training programme in Venezuela) laparoscopic RY gastric bypass. The surgeon participated in 4-6 Co-Author: Alberto Salinas1 operations every day for 6 months. The operation was divided in two steps, in which the surgeon achieved experience. An upper step 1. Hospital de Clinicas Caracas, Caracas, Dtto Capital, Venezuela. including insertion of ports, creation of the gastric pouch, 2. Universidad Central de Venezuela, Caracas, Venezuela. mobilization of the pancreatico-biliary limb from the ligament of Treiz and suturing the gastro-jejunostomy. The lower step included Background: Up to date there is no common approach for the mobilization of the alimentary limb, suturing the jejuno-jejunostomy assessment of the psychosocial profile of obese patients undergoing and leak test. Morbidity, operation time and patient flow should be gastric bypass. The purpose of this research was determine the unchanged during the fellowship programme. psychosocial profile of patients with morbid obesity undergoing Results: The surgeon participated in 300 operations during 6 months. gastric bypass. He performed 61 upper procedures, 129 lower procedures and in 110 Methods: It was constructed and validated by expert judgement an cases he performed both under supervision of the senior surgeon. interview format, which was administered to a randomized sample of There were no leaks. Two patients undervent re-operation because of 185 patients (122 female and 63 male) during the years 2002, 2003 intraperitoneal bleeding, one were reoperated because of a stenosis of and 2004 (mean age 34 years, mean BMI 44.47). The information the jejuno-jejunostomy and 2 patients undervent gastroscopy because was categorized by content analysis and results were treated with Chi of internal stapler bleeding. There were no cardiopulmonary events. Square. The mean operative time was 56/55/70 min for patient no. 0-100/100- Results: 93 patients (50.27%) reported health conditions associated 200/200-300. Eighty-five % of the patients were discharged the day with overweight like principal motivation in order to undergo after the operation. surgery; 118 (64%) work in sedentary activities; 132 (71.4%) live in Conclusion: Intensive training in a high volume center using a cities with a stressful lifestyle. History of obesity starting in structured training programme eliminates learning curve related childhood or adolescence in 102 patients (55.1%) and repeated and morbidity in laparoscopic gastric bypass surgery with no effect on unsuccessfully efforts to lose weight in all of the sample. 112 patients operation time and patient flow in the clinic. (60.5%) describe desinhibition and compulsive intake; 154 didn‟t practice sport activities (83.2%); 154 (83.24%) report direct family history of obesity and 115 patients (62.2%) had a limited social O-060 Learning Curve For Roux-En-Y Gastric Bypass integration. Total sample indicated the need to restore their quality of life through surgery. Among the preoperative stress sources are the PRESENTER: Kesava Reddy Mannur (Homerton University application of anesthesia, dying, the surgical pain, the immediate Hospital) postoperative period, having complications and not being able to lose weight. Co-Authors: Momotaz Sulatana1, Harun Thomas1, Samrat 1 1 1 Conclusion: The results obtained in our center are similar as other Mukherjee , Kalpana Devalia , Luigi Angelini researches around the world.

1. Homerton University Hospital, London, United Kingdom. O-062 Outcomes Of Roux-En Y Gastric Bypass For Patients Background: Roux-en-Y gastric bypass (RYGB) is a technically With BMI <35 Kg/M2 demanding procedure with a steep learning curve. This learning curve can be defined in terms of morbidity or length of surgery. There are PRESENTER: Sayeed Ikramuddin (University of Minnesota) conflicting reports on the number of cases needed to overcome the learning curve. Co-Authors: Daniel Leslie1, Therese Swan1, Bridget Slusarek1, Methods: Retrospective review of our prospective bariatric database Federico J. Serrot1, Henry Buchwald1 to identify the first 49 cases of RYGB performed independently by an 1. University of Minnesota, Minneapolis, MN, United States. O-064 Venous Carbon Dioxide Embolism In Laparoscopic Bariatric Surgery – Damocles Sword? Background: Since Dr. Fobi‟s publication, no lab-based type 2 diabetes outcomes exist for bariatric surgery in BMI <35 kg/m2. PRESENTER: Kalpana Devalia (Homerton University Hospital) Current NIH guidelines recommend that patients with a BMI >35 and co-morbid illness are suitable for bariatric surgery when properly screened. These criteria were developed in an era of significant Co-Authors: Harun Thomas1, Momotaz Sulatana1, Samrat morbidity associated with bariatric surgery. Comprehensive case- Mukherjee1, Kesava Reddy Mannur1 control data are lacking. We report outcomes on a cohort of patients with a BMI <35 immediately prior to surgery. Methods: We retrospectively reviewed our IRB approved database of 1.Homerton University Hospital all patients undergoing bariatric surgery at the University of Minnesota between January 2001 and February 2009. All patients Background: A safe approach to establish pneumoperitoneum is vital met initial NIH criteria for bariatric surgery at intake and evaluation. in laparoscopic bariatric surgery. Intra-abdominal pressure up to 15 For various reasons, including mandatory preoperative weight loss, mm Hg is maintained intraoperatively. Carbon dioxide (CO2) gas BMI fell below 35 in a cohort of patients. embolism is uncommon but potentially lethal complication of Results: We identified 11 female patients with BMI <35 and greater laparoscopic surgery. We report 4 cases of suspected carbon dioxide than one year follow up (mean 33.8 months). Mean pre-op BMI was embolism with favourable outcome. 34.1 (range 32.9-34.9). Mean age was 49 years. Six patients Methods: We reviewed 953 bariatric procedures from our underwent laparoscopic and four open RNY Gastric Bypass (RYGB); prospectively maintained database from January 2004 to January one was takedown of prior anti-reflux surgery with conversion to 2010 to identify the Veress needle induced CO2 embolism. Veress RYGB. After surgery mean BMI was 24.2. Mean percent excess needle is introduced at Palmers point for CO2 insufflation and first weight loss was 82.4 and mean %WL was 28.8. Type 2 diabetes was trocar introduced in midline approximately 20cm from the present in 4 patients, with two requiring insulin. Mean HbA1c fell xiphisternum. The remaining trocars are introduced under vision. We from 8.0% to 6.9%.Two patients remained on oral meds. analysed the effects it had on Pulmonary End-Tidal CO2 (P ET C02) Readmission and complications will be presented. and on the heart. Conclusion: RYGB appears safe for patients with a BMI <35. This Results: In 4 patients, P ET CO2 dropped significantly after 200- paper provides important preliminary US data for design of 300ml of CO2 insufflation. Two patients went into asystole. Carbon controlled clinical trials. dioxide embolism was suspected and insufflation stopped immediately except in one where it was delayed until after a litre of O-063 Pre-Operative Predictors Of Anemia After Gastric Bypass CO2 insufflation. The proposed operation was undertaken in all after initial stabilisation of about 20 minutes. The liver injury by the Veress needle was noted at laparoscopy. The cause of embolisation PRESENTER: Wei Lee (Min-Sheng General Hospital) was due to accidental Veress needle introduction into liver with consequent CO2 embolisation into the large venous system and right ventricle. Where the diagnosis was delayed, the patient remained Co-Authors: Jun-Juin Tsou1, Yi-Chih Lee1, Jung-Chien Chen1, obtunded but haemodynamically stable for 24 hours. There was no Kong-Han Ser1, Yen-How Su1, Shu-Chu Chen1 residual neurological deficit. Conclusion: High degree of suspicion, prompt cessation of CO2 1. Surgery, Min-Sheng General Hospital, Taoyuan, Taiwan. insufflation and resuscitation is key to successful outcome in patients with CO2 embolism.

Background: Anemia is the most prominent side-effect after gastric O-065 A Post-Anesthesia Care Unit (PACU) Protocol For bypass (GB). The aim of this study is to investigate the predictors of Reduction Of Respiratory Insufficiencies Following Roux-En-Y anemia after GB. Gastric Bypass Methods: From 1999 to 2008, 824 bariatric patients (mean age 31.6 ±9.3 years; BMI 40.6 ± 7.6) consecutive with at least 1 year‟s follow- PRESENTER: Sandra Reeder (Florida Hospital Celebration up were examined. Among all, 620 (75.2%) received GB and others Health) 204(24.8%) received restrictive type procedures. The incidence of anemia before and after bariatric surgery was examined. Anemia was defined by hemoglobin (Hb) under 13 mg/dl in male and 11.5 mg/dl Co-Authors: Patricia J. Toor1, Keith Kim1, Cynthia K. Buffington1 in female. All the clinical data were prospectively collected and stored in a personal computer system. Results: Of the patients, (5.5%) had anemia at pre-operative study 1. Metabolic Medicine and Surgery Institute, Florida Hospital and increased to 25.8% one year after bariatric surgery. The anemia Celebration Health, Celebration, FL, United States. is significantly higher in patients received GB than in restrictive type surgery (30% vs. 13.2%, p< 0.05). In univariate analysis, patients Background: Individuals having Roux-en-Y gastric bypass (RYGBP) who had anemia after GB was female predominant, older, shorter, are at risk for respiratory insufficiency early post-operatively. We had lower Hb, albumin, total protein, mean corpus volume (MCV) have developed a PACU protocol to reduce the incidence of and Ca levels than these without anemia. Lower MCV, albumin and respiratory insufficiency following RYGBP. Ca remained as an independent predictor of anemia development Methods: Patients in PACU with the following conditions are further after multivariate logistical regression analyses (P <0.000). Data evaluated: 1) unable to wean to 3 L nasal cannula or less and mining analyses confirmed that is the most important predictor of maintain an oxygen saturation level equal to or greater than 94%, 2) anemia development after surgery. symptoms or signs of confusion or agitation, and 3) unable to wean Conclusion: Anemia is very common after GB and occurs despite patients from 100% non-rebreather mask. Further evaluation includes multivitamin supplementation. Pre-operative albumin, MCV and Ca an arterial blood gas order and an intensivist/pulmonologist level may serve as pre-operative predictor of anemia after GB. consultation, with overnight monitoring in the Intensive Care Unit (ICU). Results: Prior to establishing the PACU respiratory protocol, 3.4% of Endoscopic Treatment Of 12 Cases RYGBP patients experienced respiratory decompensation requiring emergent transfer to the ICU within two hours of being admitted to PRESENTER: Eduardo Franca (Federal University of the bariatric unit. Following initiation of the PACU protocol, of more Pernambuco) than 300 RYGBP patients, none (zero) have experienced respiratory insufficiency requiring an ICU upgrade. Conclusion: Utilization of this PACU protocol, along with early and Co-Authors: Josemberg M. Campos1, Manoel P. Galvao Neto2, Luis aggressive evaluation and intervention, may reduce potential life- F. Evangelista1, Joao Paulo C. Martins1, Luciana T. Siqueira1 threatening respiratory insufficiency. Federal University of Pernambuco O-066 Laparoscopy-Assisted Transgastric Ercp And Papillotomy In Gastric Bypass Bariatric Patients. Initial Series Of 16 Cases. 1. Surgery, Federal University of Pernambuco, Recife, Pernambuco, Brazil. PRESENTER: Manoel Galvao Neto (Gastro Obeso Center) 2. Gastro Obeso Center, Sao Paulo, Sao Paulo, Brazil.

Background: Gastrobronchial fistula (GBF) is a rare complication Co-Authors: Marcelo Falcao3, Josemberg M. Campos2, Almino C. following bariatric surgery. Traditional fix is by means of toraco- Ramos1, Eduardo Franca2, Ervaldo Alves3, Thiago Secchi1, Luis F. Laparotomy has morbidity rates. Endoscopic treatment is an option Evangelista2, Alvaro Ferraz2 on this complication. Methods: 12 patients (8 RYGB and 4 SG) from 11 Brazilian bariatric 1. Surgery, Gastro Obeso Center, Sao Paulo, Sao Paulo, Brazil. services referring patients to 3 endoscopic services were 2. Surgery, Federal University of Pernambuco, Recife, Pernambuco, retrospectively evaluated within 2004 to 2009. After stabilizing the Brazil. clinical pos-op status, patients begin endoscopic treatment. GBF 3. Surgery, Nucleo de Tratamento e Cirurgia da Obesidade , diagnosis varied from 1-20m (M=10.5m) post-op (all patients had Salvador, Bahia, Brazil. acute gastro-cutaneous fistula). GBF identified by symptoms, radiology and endoscopy. CT-scan had also identified pulmonary abscess in 8 patients. Endoscopy shown gastric pouch outlet Background: Roux-and-Y Gastric Bypass (RYGB) by its nature stenosis(GPOS) and fistulas at angle of His in all patients. poses as a challenge when biliary tree access is needed. An Results: The endoscopic treatment aims on effectively dilated the alternative is to perform the ERCP trough a laparoscopic created GPOS in order to achieve at least 20mm diameter. Dilation balloons gastrotomy witch keeps the regular endoscopic duodenal anatomy (8 patients), Estenotomy with needle-Knife (7 patients) and self- ameliorating the difficulties of access expandable covered prosthesis (6 cases) were applied. GBF healing Methods: Prospective case series study over patients submitted to was achieved at 1-10m (m=5.2m). Patients that had used prosthesis RYGB due to morbid obesity that had developed biliary tree diseases had shorter healing period (m=2.3m). Concomitant procedure during needing ERCP. From January of 2003 to December of 2008, 16 treatment happens as 7 abscess drainage, 4 silastic rings removal, patients (12 female) with a time gap from RYGB to ERCP of 9-26m feeding gastrostomy in 4 and jejunostomy in 1 patient. None of those (m=16.6m), BMI at ERCP of 28.6 (+/- 3,04). Patients were submitted procedures were due to complication on endoscopic procedure to a Laparoscopy-assisted transgastric ERCP procedure. Technique: 4 Conclusion: GBF post bariatric surgery is a complex situation that trocar lap access; gastrotomy on anterior wall of excluded stomach 6 comes out with a late diagnosis and G-J stenosis in this series. cm from the pylorus near to the greater curvature; duodenoscope Endoscopic treatment has shown to be safe and effective. Also high passed trough a 18mm trocar located on LUQ guided into the numbers of concomitant procedures (non-treatment related) were gastrostomy; ERCP with papilotomy performed; gastrotomy site observed. closed with absorbable suture; 18mm trocar closed in-between sutures Results: All 16 patients went trough laparoscopy-assisted transgastric O-068 Lap-Banding As A First Step Surgery: From 1995 To 2010 ERCP and papillotomy and on 7 patients a concomitant cholecystectomy was also performed. In 14 patients stones were identified and removed, 2 patients had papilites with dilated CBD. PRESENTER: Jerome Dargent (Clinique Lyon-Nord) Procedure time lasts 89.0 min ( +/- 29,09) and hospital stay was 2,19 days (+/- 0,40). No complications or mortality were recorded in this current series Background: Lap-banding is still a good compromise in bariatric Conclusion: Laparoscopy-assisted transgastric ERCP in patients surgery. We have to take into consideration different periods: the submitted to RYGB seems feasible and safe. This procedure presents early stages of lap-banding, and the current period (2000-2010), e.g. a promising option to be done in most of bariatric centers after the adoption of “pars flaccida technique”. Methods: 1678 patients (81% F, 19% M) were operated on. Mean BMI has been 43 (33-81). Mean EWL has been 52% at 10 years. We separated three distinct periods: 95-99 (717 patients), 00-04 (531) and 05-09 (448) and reviewed the global rates of complications. Only the first and/or more significant complication was taken into account, and only the complication having led to reoperation. Results: table Conclusion: 1995-1999: Band slippage and erosion were supposed dreadful and common issues. They were kept under control.

1999-2010: Long-term food intolerance and esophageal dilatation were more important issues. Yet for patients of the initial series who O-067 Gastrobronchial Fistula After Bariatric Surgery. were observed during the second period, final erosion and slippage rates were high.

Complications of the lap-band

0-5 years 0-10/15 years 95-99: slippages 6,5% 16,4% 95-99: erosion 0,7% 4,8% 95-99: others 0,55%. Total: 7,7% 6,5%. Total: 27,7% 00-04: slippages 3,9% 9% 00-04: erosion 0,75% 1,8%

00-04: others 1,8%. Total: 6,4% 7,3%. Total: 18,1%

05-09: slippages 5,3% O-070 Influence Of Number Of Visits And Band Adjustment On 05-09: erosion 0,6% Weight Loss After Gastric Banding 05-09: others 2,9%. Total: 9,8% PRESENTER: Pablo Omelanczuk (Centro Quirurgico de la Obesidad)

O-06 9 The Realize™ Gastric Band Injection Port Strain-Relief Becomes Easily Dislodged And Represents A Potentially Co-Authors: Natalia Pampillon1, Jorge A. Nefa1 Hazardous Design Flaw 1. Centro Quirurgico de la Obesidad, Mendoza, Mendoza, Argentina. PRESENTER: Danny Sherwinter (Maimonides Medical Center) Background: To determine the relationship between the number of visits, band adjustments and weight loss one year after adjustable Co-Authors: Jesus Hidalgo1, Harry Adler1, Jerzy Macura1 gastric banding (AGB). Methods: Eighty patients (49 females and 31 males) were followed 1.Maimonides Medical Center, Brooklyn, NY, United States. up one year after AGB. Pre-operative BMI was 46.4+- 6.9 kg/m2. Four groups were identified in relation to the number of post- Background: Realize gastric band injection ports come equipped with operative visits: Group 1: less than 2, Group 2: between 2 and 6, a strain-relief reinforcement tubing designed to prevent tubing Group 3: between 7 and 12, Group 4: more than 12. fracture. Unfortunately we have found that this protector comes loose The number of visits and of band adjustments was correlated with the easily and not only leaves the tubing unprotected but poses the percentage of excess weight loss. potential for leaving a foreign body behind during port or band Results: Group 1(n=18). Pre-operative BMI 47.2 with excess weight explantation loss of 22.7 ± 12.8 %. Number of adjustments 0.8 ± 0.7. Methods: Four cases were reviewed. Two cases were patients who Group 2 (n=18). Pre-operative BMI 44.83 kg/m2 with excess weight had their Realize ports explanted due to port infections, one case had loss of 33.7 ± 21 %. Number of adjustments 1.5 ± 0.9. the entire system removed due to intolerance and one case was a Group 3 (n=35) Pre-operative BMI 46.40 kg/m2 with excess weight patient undergoing an unrelated laparoscopic procedure. In all four loss of 47.5 ± 18.1 %. Number of adjustments 1.9 ± 1. cases the strain-relief was noted to have dislodged from its port. Group 4 (n=9) Pre-operative BMI 51 kg/m2 with excess weight loss Results: In the three explantation cases, the strain-relief could not be of 49.2 ± 15.6 %. Number of adjustments 2.6 ± 1. retrieved due to implantation of the strain-relief into the Conclusion: The higher the number of post-operative visits, the intraabdominal tissue or abdominal wall musculature. In the higher the percentage of excess weight loss. The minimum number of incidental finding case the strain-relief was noted to be free floating annual visits should be more than 7 and the optimal number more along the length of the gastric band‟s tubing. than 12. This favors a change in the eating behavior necessary to Conclusion: Dislodgement of the strain-relief portion of the Realize obtain good results in AGB surgery. The number of adjustments was gastric band port occurs spontaneously. We feel that this represents a slightly higher in patients with more control visits. design flaw that could lead to potentially serious consequences for patients. Although a redesign of the system is clearly necessary, until O-071 Insufficient Weight Loss After Biliopancreatic Diversion/ this occurs clinicians must be vigilant when removing a Realize band Duodenal Switch: Incidence, Prevention And Treatment. or port to be conscious of this potential problem. PRESENTER: Yury Yashkov ( CELT-clinic)

Co-Author: Anton V. Nikolsky2

1. Surgery, CELT-clinic, Moscow, Russian Federation. 2. Surgery, Railway Hospital, Smolensk, Smolensk, Russian Federation.

Background: Every bariatric operation especially simple restrictions may lead to insufficient weight loss or its regain in the late period. BPD and its modification –Duodenal Switch (BPD/DS) is known to provide the most stable weight loss results. However, some patients PRESENTER: Giovanni Dapri (European School of are also tended to weight regain after its stabilization Laparoscopic Surgery) Methods: 235 patients underwent BPD/DS in the CELT-clinic within 2003-2009. 156 of them achieved weight stabilization. Their maximal Co-Authors: Guy-Bernard Cadière1, Jacques Himpens1 EWL to the period of stabilization was 83,4 % at 21,4 + 10,8 months, while final % EWL at 39,6 +14,4 months postop. was 75,8%. We 1. Department of Gastrointestinal Surgery, European School of analyzed the cases of poor weight loss (EWL < 50 %; n-11; 7,1%) Laparoscopic Surgery, Brussels, Belgium. and weight regain to EWL < 50% (n-8; 5,1 %) after BPD/DS.

Results: The percentage of patients with EWL< 50% was at 2,3,4 and Background: This study reports the feasibility, safety, and outcomes 5 years was accordingly 5,1; 4,2; 9,2; 3,2 %. 13 patients had of laparoscopic reconversion of Roux-en-Y gastric bypass (RYGB) to shortening of common limb (CL) + resection of alimentary limb (AL) original anatomy (OA), as treatment of side effects like dumping usually together with abdominoplasty. In 8 of them EWL was syndrome and weight loss issues. improved but half of them re-started to regain weight later. 1 more Methods: Between January 2005 and April 2008, 8 patients benefited patient had re-resection of Gastric Sleeve with excellent result. from laparoscopic reconversion of RYGB to OA. Reason was Conclusion: %EWL < 50% was observed after BPD/DS in 4-5% at 3 exaggerated dumping syndrome (3), intolerance to RYGB induced years but increased to 9,2% to 4-th year. Shortening of CL + restriction (3), too much weight loss (1), and too little weight loss (1). resection of AL may improve results but some patients were then Mean weight, BMI at RYGB was 104.7 kg (73-131), and 38.7 kg/m2 tended to regain weight. Additional restriction seems to be more (30-46) respectively. Four patients suffered of obesity related co- important in case of insufficient weight loss after BPD/DS morbidities. Mean time between RYGB and reconversion was 21 months (7-60). Mean weight, BMI, %EWL at reconversion was 66.8 O-072 Does Pregnancy Increase the Need for Revisional Surgery kg (48-110), 20.1 kg/m2 (16.6-38), and 23.7 % (0-122.3) after Laparoscopic Adjustable Gastric Banding? respectively. The procedure involved dismanteling both gastrojejunostomy and jejunojejunostomy, reanastomosing gastric PRESENTER: Rebecca Haward (Centre for Obesity Research pouch to gastric remnant, and proximal alimentary limb end to distal and Education ) biliary limb end. Results: Mean operative time was 132.2 min (95-180). There were no Co-Authors: Rebecca N. Haward1, Wendy A. Brown1, Paul E. conversions to open surgery, and no early complications. O'Brien1 Gastrogastrostomy was performed manually (4), and by linear stapler (4), and jejunojejunostomy by linear stapler (8). Mean hospital stay 1. Centre for Obesity Research and Education, Melbourne, VIC, was 7.7 days (5-13). After a mean follow-up of 18.3 months (7-36), 2 Australia. patients continued to further lose weight, with a drop in BMI to 27 and 25.5 kg/m2 respectively, 2 patients maintained the same weight Background: Over 80% of laparoscopic adjustable gastric banding as at reconversion, and 4 patients presented a mean weight regain of (LAGB) patients are women and approximately half of these of 20.2 kg (7-32), with a mean increased BMI to 28 kg/m2 (25-31.5). reproductive age, therefore pregnancy after LAGB is common. During follow-up, gastroesophageal reflux disease appeared in 3 Studies indicate pregnancy after LAGB is safe for mother and child, patients. however it is unknown if pregnancy increases the need for revisional Conclusion: Laparoscopic reconversion of RYGB to OA is feasible procedures. We compare the incidence of revisional surgery in two and safe. In case of conversion performed for weight issues, the matched cohorts of LAGB patients with or without a subsequent anatomy is just one aspect of the problem besides the psychological pregnancy. factors.

Methods: From September 1994 – May 2009, 5467 patients O-074 Upper Endoscopy Results In Patients With Failed Roux- underwent LAGB at the Centre for Bariatric Surgery, Australia. En-Y Gastric Bypass Women with births post-LAGB were compared to matched controls, with a„ matched follow-up date‟ calculated equivalent to pregnancy. The rates of primary and overall revisions for band complications PRESENTER: Atul Madan (Beverly Hills Surgery Center) (erosions, proximal pouch dilatations) and port/tubing complications at 2 and 3 years after pregnancy were calculated. The relationship to factors including LAGB management during pregnancy was Co-Authors: Pejman Samouha1, Salman Khan1, Michael Omidi1, investigated. George Tashjian1, Julius Gee1, Julian Omidi1

Results: 189 women had ≥1 pregnancies after LAGB, including 137 1. Beverly Hills Surgery Center, Beverly Hills, CA, United States. with follow-up at least 2 years and 104 at 3 years post-pregnancy. There was no significant difference in the number of band or port/tubing revisions between groups at either timepoint (p=0.13 and Background: While Roux-en-Y gastric bypass has been demonstrated p=0.09 for primary band revisions, and p=0.84 and p=0.35 for to be an effective procedure for weight loss in morbidly obese primary port/tubing revisions at 2 and 3 years respectively). LAGB patients, it is estimated that at least 20% of patients regain weight or management during pregnancy had no effect on revisions, however have insufficient weight loss. Considering the increase of number of less time between LAGB and pregnancy was associated with a higher bariatric surgery procedures, a greater number of gastric bypass rate of primary band revisions (p=0.03). patients will present as “failures”. The cause of these “failures” should be investigated. Endoscopy is one modality which is utilized Conclusion: Results suggest that pregnancy after LAGB does not to determine any technical causes of “failures”. The hypothesis of affect re-revision rate, however a shorter time between LAGB this study was that upper endoscopy would help determine any operation and pregnancy may predispose to band-related revisions. potential anatomical causes of “failures”. Methods: All patients, who presented to our practice that had O-073 Laparoscopic Reconversion Of Roux-En-Y Gastric Bypass previous Roux-en-Y gastric bypass and underwent upper endoscopy, To Original Anatomy: Technique And Preliminary Outcomes were included in the study. Patients had either gained weight or had insufficient weight loss. A bariatric surgeon who had extensive experience in endoscopy and bariatric surgery performed all Macadam1, David Kerrigan1 endoscopies. Results: The time period of this study was 10/2009 to 2/2010. There 1. Gravitas Centre for Bariatric Surgery, Liverpool, United Kingdom. were 35 patients included in this study. The gender distribution was 4:31 (M:F). All patients had potential anatomical causes of their “failures”. Most patients had a large (> 2 cm) gastrojejunostomy Background: Although vitamin D depletion after bariatric surgery is (33/35). Enlarged (>6 cm and/or “fat”) pouches were also noted in well documented, several reports have suggested that morbidly obese most (34/35) patients. A long blind jejunal limb was noted in 26/35 individuals may also be susceptible to pre-existing vitamin D patients. deficiency. This is of particular concern for patients considering a Conclusion: In our study, potential anatomic issues were noted in malabsoptive procedure and highlights the potential importance of patients that had a Roux-en-Y gastric bypass and who are considered pre-operative vitamin D screening. We determined the prevalence of “failures”. Any bariatric surgery patient who presents with pre op vitamin D depletion in patients being considered for insufficient weight loss or weight regain should undergo upper malabsorptive bariatric surgery. endoscopy. Surgical interventions may be helpful in many patients Methods: 145 consecutive patients (113 female and 32 male) had who are “failures” after Roux-en-Y gastric bypass. their vitamin D levels checked pre-operatively. Median age was 46 years and median BMI was 50.6 Kgm2. Chi -squared tests were used for statistical analysis O-075 Changes In Body Composition After Bariatric Surgery Results: 55% of patients had evidence of vitamin D depletion (26% Among Morbidly Obese Japanese Patients deficient and 74% insufficient (based on lab assay interpretation guide). There was no significant difference between males and PRESENTER: Yosuke Seki (Yotsuya Medical Cube) females (CHI squared =0.178), and age over/under 50 years (CHI squared =0.130) and BMI over/under 50Kgm2 (CHI squared =0.173) did not influence the incidence of vitamin D depletion. Co-Authors: Kazunori Kasama1, Makoto Kinouchi1, Hideharu Conclusion: The results of this study show that many bariatric Shimizu1 patients have pre-op vitamin D depletion irrespective of gender, age or BMI. These findings support the need for pre-operatively vitamin D testing in all patients considering a malabsorptive procedure. 1. Weight loss surgery, Minimally invasive surgery center, Yotsuya Medical Cube, Chiyoda-ku, Tokyo, Japan. O-077 Gastric Band Erosion: A Two Year Experience And Clinical Analysis Background: The number of bariatric surgery performed worldwide has been continuously increasing. As long as western morbidly obese individuals are concerned, weight and fat body mass decrease PRESENTER: Mario Rodarte (Hospital San Jose - TEC de significantly compared to LBM (lean body mass) after bariatric Monterrey) surgery. It is well-known that Asian people are more prone to central obesity than Western people. Moreover, dietary culture in Asian countries is different from that in Western countries. There are few Co-Authors: Roberto A. Rumbaut1, Rodrigo Merino1 studies investigating body composition change after bariatric surgery for Asian. 1. Bariatric Surgery, Hospital San Jose - TEC de Monterrey, Methods: 113 patients undergoing bariatric surgery were included in Monterrey, Nuevo León, Mexico. this study. The patients were measured total body fat mass weight, body skeletal muscle weight, total body water weight, basal metabolic rate, using a bioelectrical impedance analysis as well as body weight, BMI, and waist/hip ratio. Measurement of visceral and Background: Gastric band erosion represents a complication reported subcutaneous fat area were also performed using abdominal CT in 0.5 – 3.8% of patients with a gastric band. images pre and 1 year after surgery. Methods: We identify retrospectively patients treated for band Results: Body weight, BMI, waist/hip ratio, total body fat mass erosion in 2008 – 2010. Variables obtained were age, sex, body mass weight, body skeletal muscle weight, total body water weight, basal index (BMI) prior to adjustable gastric band (AGB), BMI after AGB, metabolism decreased significantly during the first month after BMI at diagnosis of band erosion, time of diagnosis after AGB surgery. Body skeletal muscle weight also decreased, but the impact placement, diagnostic methods and main complaint by which patient was minimal. Consequently, fat mass per body weight-kg decreased was diagnosed with gastric band erosion. between pre and after surgery, whereas skeletal muscle per body Results: We managed 6 cases with a mean age of 44 years (30 - 60) weight-kg increased. Fat distribution analysis demonstrated that there being 4 female and 2 male. Mean BMI at the placement of the AGB was significantly more visceral fat area decrease than subcutaneous was 45 (38.1 – 52). All the patients had an acceptable body weight fat area. loss until a mean time of 8 years (3 – 14) when gastric band erosion Conclusion: Body fat mass, rather than LBM, effectively decreases diagnosis was made. The main complaint accompanying band after bariatric surgey in Asian morbidly obese individuals. erosion was weight regain (4/6, 66%), port site changes (4/6, 66%), Postoperative visceral fat decrease seemed to be related to the upper gastrointestinal symptoms - pyrosis, dysphagia, epigastric pain improvement of obesity related co-morbidities. – (1/6), 16% and malnutrition (1/6, 16%). In the six patients the diagnosis was suspected clinically and by fluoroscopic examination, and finally confirmed by endoscopy. The 6 patient were taken to O-076 Prevalence Of Vitamin D Depletion In Patients surgery for laparoscopic removal. One patient was converted to a Considering Malabsorptive Bariatric Surgery vertical sleeve gastrectomy and died from abdominal sepsis. The rest of the patients evolved favorable. PRESENTER: Jayne Brocklehurst (Gravitas Centre for Conclusion: Gastric band erosion represents a rare complication that Bariatric Surgery) requires surgical removal of the eroded band. Weight regain and port site changes represent the main clinical presentation. Diagnostic procedures should include fluoroscopy and endoscopy when Co-Authors: Conor Magee1, Simon Weaver1, Shafiq Javed1, Robert clinically suspected. gastro-jejunal estenosis with a gastric leak. Conclusion: Morbidity was high, equally frequent when revision involved pouch reconstruction. Previous Nissen Funduplication needs special attention.

O-80 Revisional procedures after Bariatric Surgery: Experience at Hospital San José-Tec de Monterrey (Mexico)

PRESENTER: Roberto Rumbaut (Hospital San Jose-TEC de Monterrey)

O-078 Periodical Emptying Of The Gastric Band System Reduces Co-Authors: R. Merino1, H. Guajardo1, M. Rodarte2, L. Gonzalez3, Band Migration R. Valles4

PRESENTER: Branko Breznikar (Splosna bolnisnica Celje) Background: Ten to 25% of postoperated bariatric patients will require revision, associated with higher morbidity. Aim: To evaluate results of laparoscopic revisional bariatric surgery at our center. Background: Gastric banding is a less demanding bariatric procedure Methods: Retrospective series of revisional surgery patients, with a low complication rate. Migration , slippage and dilatation of recording demographics, indication for revision, conversion rate to the pouch still occur in too high a number of patients. We believe that open surgery, morbidity, change in EWL% and need of reoperation. periodically emptying the gastric band system improves results and Results: In a 40-month period, 59 bariatric patients required reduces the complications without significantly altering the weight laparoscopic revision because of inadequate weight loss. Primary reduction. procedures were Adjustable Gastric Banding (n=54), Sleeve Methods: Presented are the results of our experience in bariatric Gastrectomy (n=2) and Roux-en-Y Gastric Bypass (n=4). From the surgery over the last 5 years. There were 250 gastric bandings among AGB to GBP conversion group (n=42), 7 patients (16.6%) other bariatric procedures. We secure the band in place with 1-3 experienced complications, including 5 gastrojejunostomy leaks stitches of the fundus to the left crus and/or the gastric pouch. We (11.9%), 1 enteroenterostomy leak (2.3%), 1 native stomach leak monitor the patients almost monthly (individually and in the support (2.3%), 3 gastrogastric fistulas (7.1%), 3 cavity abscesses (7.1%), and group) during the first year. We empty the system for one month each 2 surgical wound infections (4.7%). Conversion rate was 4.7%. year. Reoperation for complications was required in 85%. Mortality was Results: Reduction of the body weight, band removal, and re-do 1/42 (2.3%). In the AGB to SG conversion group (n=11), operations are comparable to the literature. However, we have only complications were found in 9% (n=1): a leak in a patient that seen one migration and two slippages so far, which is significantly required laparotomy and died of upper GI bleeding. Two patients less than what the literature reports. were converted from SG to GBP. An enteroenterostomy leak ocurred Conclusion: We believe that in addition to good and frequent (50%), requiring diagnostic laparoscopy. No deaths occurred. Four monitoring of the patients, emptying the system periodically reduces patients with failed GBP, received an AGB on the dilated pouch, the number of migrations, slippages, and dilatations of the pouch. without complications. Overall morbidity and mortality was 15% and 3.3%, respectively. Conversion rate was 3.3%, and 88% of patients with complications required reoperation. O-079 Revisional Bariatric Surgery: 266 Open Cases Conclusion: Laparoscopic conversion from AGB and GS to GBP is feasible and effective. Morbimortality is up to 10 times higher PRESENTER: Alberto Salinas (Hospital de Clinicas Caracas) compared to the primary procedure, and reoperation for complications is often required.

Co-Authors: G. Acosta1, W. Garcia1, A. Parilli1, M. Antor1 O-081 Laparoscopic Adjustable Gastric Band After Roux-En-Y Gastric Bypass In An Outpatient Setting Background: Revisions in bariatric surgery are reported in the literature with high rate of morbidity and mortality. We present our PRESENTER: Atul Madan (Beverly Hills Surgery Center) experience with these patients. Methods: Between 1990 to February 2010 we performed 266 open revisional cases. The records were reviewed. Early morbidity was Co-Authors: P. Samouha1, S. Khan1, M. Omidi1, J. Gee1, G. obtained and related with the type of revision. Tashjian1, J. Omidi1 Results: There were 57 males and 211 females. The mean age was 39 years with a mean BMI of 38 kg/m2. There were 127 Vertical Gastroplasties converted to a Gastric Bypass (GBP), 11 (8,6%) had Background: Weight regain after Roux-en-Y gastric bypass (RYGB) Gastric Leaks (8 gastric, 3 gastrojejunal, 1 death), 4 (3%) Upper GI is not uncommon. Some surgeons have suggested placing a (UGI) bleeding, and 1 (0,7%) jejunojejunal leak. 59 patients laparoscopic adjustable gastric band (LAGB) over an enlarged pouch underwent Gastric Transections because pouch enlargement or for patients who have gained weight after RYGB. While primary gastro-gastric fistula, 6 (10%) gastric leaks and 1 (2%) UGI bleeding. LAGB has been described in an outpatient setting, LAGB after There were 70 revisions to a GBP from Gastric Banding (41 gastric RYGB in the outpatient setting has not been studied. Our study segmentation, 39 adjustable bands) with 6 (8,5%) gastric leaks (5 examined the hypothesis that LAGB after RYGB can be performed gastric, 1 gastro-jejunal), 1 (1,4%) UGI bleeding, 1 (1,4%) acute safely in the outpatient setting. gastro-jejunal stenosis. We converted 8 patients from proximal to Methods: All patients who underwent LAGB after RYGB were distal GBP, with one jejunojejunal leak. We had 4 patients with included in this study. A retrospective chart review was performed to previous Nissen Fundoplication, 3 of them had a gastric leak. 3 examine the work-up and results of patients. This study focused on patients were converted from jejunoileal to a GBP, 1 had an acute perioperative results only. Results: There were 6 patients operated over a 4-month period. we analyse a large series of patients in whom conversion in this Patients were evaluated in a multi-disciplinary clinic. Preoperative setting was performed using a laparoscopic approach. work-up included nutritional counseling, psychological evaluation, Methods: Prospective data collection in each centre, and retrospective medical clearance, cardiology clearance, barium study, and upper analysis of pooled data. endoscopy. All patients had radiological and/or endoscopic evidence Results: 198 patients were re-operated between 1998 and 2009 in our of enlarged pouch as well as enlarged gastrojejunostomy. All patients four hospitals, 170 women and 28 men, with a mean age of 44,5 underwent successful outpatient LAGB after RYGB. The average years (22-68). The mean interval between VBG and conversion was operative time was 110 minutes (Range 70 – 152). There were no 110 months (12-216). The mean BMI before VBG was 43,3 (24-65), conversions and no complications. Patients were followed in the and the mean BMI before reoperation was 37,6 (18-64). The main office in less than a week after surgery (per protocol). No patients indications for reoperation were weight regain (61.6 %) and severe were admitted to the hospital or seen in the ER/office before their food intolerance (22.7 %). There was no conversion. 24 patients (12,1 scheduled appointment. %) developed complications, including 9 (4,5 %) with major Conclusion: LAGB after RYGB can be performed as an outpatient complications. One patient died (mortality 0.5 %) on POD 6 as the procedure safely. Further investigations should include larger number consequence of a strangled incisional hernia. The mean BMI after 1, of patients and longer-term follow-up to demonstrate the 3, 5, 7 and 9 years was 28.9, 28.1, 28.7, 29.4 and 31.4 respectively. effectiveness as LAGB as a revisional procedure for patients who At these terms, 86.2, 89, 90.2, 82.2 and 100 % of patients had a BMI have failed RYGB. < 35. Conclusion: Laparoscopy can be considered as a safe approach for conversion to RYGBP after failed or complicated VBG. Results are O-082 Is Weight Loss In Revisional Laparoscopic Roux-En-Y comparable to the open approach regarding risks, and are similar to Gastric Bypasses Similar To Primary Bypasses? those of primary RYGBP regarding weight loss.

PRESENTER: Kamal Mahawar (Sunderland Royal Hospital) O-084 Indications, Complications And Long Term Outcomes Of Remnant Gastrectomy For Gastro-Gastric Fistula After Divided Roux-En-Y Gastric Bypass For Morbid Obesity Co-Authors: M. Boyle2, S. Balupuri1, P. K. Small1

PRESENTER: Emeka Acholonu (Cleveland Clinic Florida) Background: We had carried out 200 laparoscopic roux-en-Y gastric bypasses (LRYGB) at our centre till November‟ 2009. A number of these were revisional bypasses carried out for unsatisfactory weight Co-Authors: J. Eckstein1, S. Patel1, S. Szomstein 1, R. J. Rosenthal 1 loss with prior bariatric procedures. The purpose of this study was to find out if the weight loss was similar in primary and secondary bypasses. Background: GGF is a rare complication after divided RYGBP for Methods: Patients undergoing LRYGB were divided into two groups. morbid obesity. Medical management has proved grossly ineffective. Group 1(n-175) comprised of primary gastric bypasses and Group 2 Less invasive methods like fibrin glue and sealants via an endoscopic (n-25) consisted of revisional procedures [failed gastric bands (24) or approach have been reported with recurrence rates as high as 75 %. vertical banded gastroplasty (1)]. Data regarding weight loss were Methods: After IRB approval and following HIPAA guidelines, we obtained from a prospective database. retrospectively analyzed our prospectively collected database for Results: Mean BMI at the time of referral was 51.77 and 51 2226 patients that underwent LRG for GGF after divided RYGBP respectively in Group 1 and 2. Mean excess body weight loss between April 2001 and September 2008. RYGB divided were (EBWL) at 6 weeks postoperatively was 27.2 % (Range: “0.00- 57.1, completed over this period as well as referred cases from outside Median- 27.6) in Group 1 and 27.6 % (Range: 11.6-39.9, Median- institutions. The procedure entails dissecting out the pouch and 27.7) in Group 2 (p value 0.97 on unpaired t test). Six months remnant stomach, stapling off the GGF and transecting the remnant following bypass, the mean EBWL was 49.9% (Range: 11.7-99.6, stomach at the antrum. A total of 60 cases were completed. Our Median 48.2) and 46.7%(Range: 32.2-76.7, Median-45.8) patients were followed up 10 days, 2 months, 6 months and yearly respectively in Groups 1 and 2 (p value 0.454). Difference at 1 year after discharge. follow up (Group 1: Mean- 62.5, Range 20.1-108 and Group 2: Results: There were 51 females (85%) and 9 males (15%). The age Mean- 51.6, Range 5.2-99) was not significant either with a p value range was between 25 and 68 (average 45), the BMI ranged between of 0.068. Similarly at 2 year follow up (Group 1: Mean- 62.6, Range 20 and 58.7 (average 36.3).The most common indication for the “-6.3”-101 and Group 2: Mean- 54,3, Range 5-88.7), there was no procedure was pain, other indications include recurrent or persistent statistical difference in EBWL in two groups. ulcers, weight regain, upper gastrointestinal bleed, intractable nausea Conclusion: Patients undergoing revisional gastric bypasses achieve and vomiting. 10 (17%) of the procedures were converted to open. weight loss comparable with primary bypasses. We did not regard conversion as a complication but as a judgment call, opting for safer treatment. There was a 15% complication rate (9 patients) and the most common complication was leakage from staple O-083 Laparoscopic Conversion To Roux-En-Y Gastric Bypass lines. Our cumulative long term outcome suggests most patients were After Vertical Banded Gastroplasty: A Three-Centre Experience satisfied with the results. 4 patients (7%) complained of persistent With 198 Patients unexplained pain. There has been no recurrence and there has been no mortality. PRESENTER: Michel Suter (Hôpital du Chablais) Conclusion: LRG seems to be a safe, feasible and reliable option to treat GGF after divided RYGB, with significant relief of symptoms and acceptable perioperative morbidity. Co-Authors: P. Millo2, S. Ralea3, J. Alle3 O-085 Roux-En-Y Gastric Bypass As A Revisional Procedure Background: Vertical banded gastroplasty (VBG) can be followed by After Gastric Banding: Leaving The Band In Place insufficient weight loss, or a number of long-term complications with or without weight regain, for which conversion to Roux-en-Y gastric PRESENTER: Gideon Latten (Atrium Medisch Centrum bypass (RYGBP) is often considered the best option. In this paper, Parkstad) O-087 Revisional Surgery After Failed Laparoscopic Adjustable Gastric Banding. An Up-To-Date Systematic Review.

Co-Authors: L. Timmermans1, R. Schouten1, B. Meesters1, J. PRESENTER: Juan Pujol Rafols (CLÍNICA TRES TORRES.) Greve1

Background: Roux-en-Y Gastric Bypass (RYGB) and Adjustable Co-Authors: L. Catot Alemany1, C. Pujol Rafols1, A. Galera Murtra1 Gastric Banding (AGB) are frequently used bariatric procedures. After years of experience with both techniques we present a series of Background: Laparoscopic adjustable gastric banding (LAGB) has a patients that needed revisional surgery after one of these procedures. failure rate between 7.9 and 58%. Many of these patients will have to A combination of both techniques was used. Safety and efficacy were be indicated for revisional surgery. The most common revisional evaluated. strategies are currently re-banding, band removal and conversion to Methods: 24 Female patients were included. Group A (n=12) gastric bypass (RYGB) or to bilio-pancreatic diversion (BPDDS). underwent RYGB after previous AGB, while group B (n=12) The purpose of this study is to determine which scientific evidence underwent AGB after previous RYGB. Seven patients in group B exists about their efficacy and morbidity. previously had a vertical banded gastroplasty. The postoperative Methods: A systematic review has been done using electronic data situation was the same in all patients: a Roux-en-Y Gastric Bypass bases such as Medline and Cochrane library. All papers published in with an adjustable gastric band around the stomach pouch. Study English from 1992 up until now were included. A total of 70 papers parameters included weight loss after both procedures and about this topic have been found and revised manually. complication rate. Results: Three cohorts of 115, 307 and 113 banded patients have Results: Median baseline BMI was 48,4 kg/m2 (Group A 52,2 versus been revised to re-banding, RYGB or BPDDS respectively. The group B 44,6 kg/m2; ns). Median %EBMIL after the first procedure indications for such operations were mainly band slippage, band was 50,3% in group A and 54,6% in group B. Median time between migration, band intolerance and inadequate weight loss. 4%, 19% and the first and second operation was 66,5 months (group A and B: 53,0 39% of the re-banding, RYGB and BPDDS patients had to be versus 70,4 months, ns). Indications for revision were weight gain operated by an open approach. The operating time and the hospital (n=16), insufficient weight loss (n=7) and passage complaints (n=1). stay vary depending on the technique; 173 minutes and 3.0 days for In group A, median follow-up after revision was 7,3 months, with a the re-banding, 182 minutes and 6.4 days for the RYGBP and 239 median %EBMIL after revision of 37,2%. Median follow-up in group minutes and 8.6 days for the BPDDS procedure. Efficacy and B was 19,7 months, with a median %EBMIL of 26,2%. The morbidity is also technique dependant. Final BMI is 34.6 with the re- difference in follow-up between both groups was significant banding, 31.1 with the RYGB and 31 with the BPDDS. Major (p=0,04). BMI at most recent follow-up was 33,7 kg/m2 in group A complication rates were 2.2, 12.5 and 11.6% respectively. No and 36,1 kg/m2 in group B (p=0,54). Complication rate and severity technique-related mortality has been registered. were low in both groups. Conclusion: Revisional surgery after failed LAGB can be performed Conclusion: Both the conversion of a previous AGB and RYGB to a safely in experienced hands. Its results vary depending on the „banded bypass‟ seems to be safe and effective. After revisional technique used. RYGB and BPDDS have demonstrated better final surgery, most patients lost weight. Randomized trials are needed to results in terms of weight loss but they are also more technical determine if there is an additional effect of leaving the band in place demanding and they report higher complication rates. when converting AGB to RYGB.

O-88 Single Incision Laparoscopic Surgery For Adjustable O-086 Laparoscopic Gastric Bypass For Failure Of Adjustable Gastric Banding. Preliminary Experience Gastric Banding: A Review Of 78 Cases.

PRESENTER: Maurizio De Luca (Regional Hospital) PRESENTER: Philippe Espalieu (Hopital Edouard Herriot)

Co-Authors: Gianni Segato1, Luca Busetto1, David Ashton2, Franco Co: Author: M. Robert1 Favretti1

Background: After 15 years of Adjustable Gastric Banding (AGB) in 1. General Surgery, Regional Hospital, Vicenza, Italy. France, the need for revisionnal surgery is increasing as the long term 2. The Healthier Weight Centre, Princess Grace Hospital, London, failure rate. United Kingdom. Methods: Datas were collected from 78 patients converted to Laparoscopic Gastric Bypass (LGBP) by the same surgeon between 2003 and 2009, for insufficient weight loss or poor functionnal results after AGB .The median follow-up was 2 years and only one Background: LAPBAND has proven to be a safe and effective patient was lost for follow-up. procedure for the management of morbid obesity. In our experience Results: Average operative time was 158 mn, mean hospital stay 5,2 Lap Band is considered first choice operation. Single Incision days. The complication rate was 10%, mortality 0%. Oesophagitis Laparoscopic Surgery (SILS) has become an exciting area of surgical was cured in all cases after LGBP. Average BMI was 46,6 prior development. AGB, 41 at the time of conversion, 34 post LGBP. Poor results Methods: Our LAPBAND series consists of 2650 Patients (Sept (15%) are linked with age (older patients) and initial BMI (super or 1993-Feb 2010). Mortality 0%. Mean %EWL 49.7. Major hyper obeses). complication requiring reoperation 5.7%. Thirteen years follow-up Conclusion: LGBP for failed AGB although technically with 91% of follow-up rate in a subset of 1800 pts. challenging,is feasible with an acceptable complication rate and SILS for LAPBAND, in our experience, consists of introducing 3 provides good functionnal results. Among european eastern patients, trocars (two trocars of 5mm and 1 trocar of 10mm) through the same the weight loss after this type of revisionnal surgery may vary upon skin incision, but with 3 different fascia incision. In 11 cases of SILS age and initial BMI. we adopted the Covidien SILS-PORT by a single fascia access.Veress needle covered by a dranaige tube for liver retraction is required. Follow-Up From October 2008 to February 2010 total series of patients underwent to SILS were 46. PRESENTER: Antonio Silva (Hospital do Carmo) Results: Mean operative time was 65 min (45-105) and increased considering the entire series (mediane 45 minutes). There were no intraoperative and perioperative complication . The Patients did well postoperatively and were discharged during the first postoperative Background: A sequential study of a group of patients followed at day. No differences in terms of perioperative pain and hospital stay least of a period of 7 years to evaluate gastric banding on the have been revealed in patients after SILS. treatment of severe obesity Conclusion: SILS for LAPBAND is technically feasible. If the Methods: All the patients were submitted a laparoscopic gastric procedure by SILS is difficult, there is indication to introduce further banding using Lapband before the end of the year 2002. Surgery was trocars. Further study are necessary for the evaluation of clinical done allways by laparoscopy, using the pars flacida technique. results at medium and long-term follow-up Patients had an intensive follow-up. 180 severely obese patients with an average BMI of 46.6 at the outset were followed with a high rate O-089 Position Of Laparoscopic Adjustable Gastric Band Not (97.8%) for seven years, 94% of the patients retained the gastric Changed By Single Incision Laparoscopic Surgery. banding. Results: 176 patients completed the 7 year follow-up study. Average % EBMI loss was at 3 years was 67% and remained stable through PRESENTER: Mustafa Hussain (NYUMC) year 7. Comorbidities present in 70% of the patients were resolved in 60%. 94% of bands continue in place, 8 patients were converted into gastric bypass or sleeve gastrectomy. No mortality. Severe morbility Co-Authors: Heekoung Youn1, George Fielding1, Christine Ren- ocurred in 15% of the patients. Fielding1, Marina Kurian1 Conclusion: Laparoscopic adjustable gastric banding is suitable for treating severly obese patients with good results and low morbidity 1. Surgery, Division of Bariatrics, NYUMC, New York City, NY, on long term United States. O-091 Intra-Operative Band Stoma Adjustment Improves Early Background: The use of single incision laparoscopic surgery (SILS) Post-Operative Weight Loss to perform adjustable gastric banding (AGB) has recently been described as feasible and safe. Limited data is available to determine PRESENTER: Robert Snow (Speciality Surgery Center of Fort if in-line surgical technique has any effect on band position and Worth) subsequent function. We undertook this study to determine if the position of the AGB on post-operative esophagram would be preserved when using SILS. Co-Author: John O'Dea2 Methods: Data was gathered from a retrospective examination of a prospective database for AGB done in 2009. Fifty cases of SILS AGB were selected and reviewed, along with matched cases of 1. Speciality Surgery Center of Fort Worth, Hurst, TX, United States. conventionally placed AGB. Cases were matched for BMI and type 2. Crospon, Galway, Ireland. of band used (LAGB AP standard, LAGB AP Large or Realize C). Post-operative esophagrams were examined for axis of band position Background: We undertook a pilot study to assess if filling a gastric (1 o‟clock, 1:30, 2 o‟clock, 2:30 or 3 o‟clock). Student‟s t-test was band, to achieve a 7mm band stoma intra-operatively, reduced post- used to compare the groups. operative weight loss versus historic controls. Results: SILS and conventional AGB groups each contained 20 Methods: 50 historical controls (37 Female) were used, and 35 LAGB:AP Standard, 10 LAGB:AP Large and 20 Realize C. The patients (28 Female) were enrolled in the study. Peri-gastric fat was mean BMI for the study and matched groups were 43.4Kg/m2 and not removed during the procedure. As the band (APS or APL, 45.8Kg/m2, respectively. Band position was in the 2 o‟clock or 2:30 Allergan Inc., Irvine,CA) was filled, the stoma size was measured axis in 88% of the study group and 91% of the matched group. directly using the EndoFLIP (Crospon Ltd., Galway, Ireland) system, Slightly more vertical position was noted in 8% and 7% or the study and a calibration table (fill volume versus stoma size) prepared for and matched groups, respectively. More horizontal position each subject. To analyze %EWL improvement at one month, we encountered in 4% and 1%, respectively. Overall these differences included patients who had a follow-up visit in weeks 4 or 5 post- were not significant. (p=0.99) operatively. Conclusion: SILS does not result in altered position of AGB. Results: Follow up data was available at Weeks 4-5 for 31 controls and 18 study subjects. Of the 35 subjects, the band was sufficiently snug in five of them (2 APS, 3 APL) that it was not possible to create a 7mm stoma. To achieve a 7mm stoma size in the remaining 30 subjects, the band fill volume required was 2.2(1) mL for the APS and 1.7(1.6) mL for the APL. %EWL for the historic controls at one month was 14.8(8.6). %EWL for study subjects at one month was 18.6(10.5). The mean %EWL improvement was 3.8 (p=0.088). None of the 35 subjects required the band to be loosened post-operatively. Conclusion: Intra-operative adjustment is well tolerated, with no patients in the study requiring their band to be loosened post- operatively, whilst at the same time permitting a 25% (3.8/14.8) %EWL improvement versus historic controls one month out from surgery.

O-090 Seven Years Sequential Study With Lap Band With 97.8% Low compliance with adjustments may have contributed to this lack of overall success. The data suggest that in a tertiary referral center for a large geographic area, LAGB may achieve less promising results than previously reported.

O-093 Long-Term Results Of Lagb In Patients With Low Bmi (Bmi 35-40 And No Co-Morbidity And Bmi<35)

PRESENTER: Nicholas Sikas (Interbalkan Medical Center)

Background: LAGB is a worldwide popular bariatric procedure. Current selection criteria do not include patients with BMI<40 and no co-morbidities and surgery is not recommended in patients with BMI<35. In this retrospective analysis we studied the safety, EndoFLIP Screen effectiveness and long-term results of LAGB in these groups of patients. Methods: Patients were offered surgical treatment after thorough, multidisciplinary work-up. The study included 147 patients with BMI 35-40 and no co-morbidities (group A) and 107 patients with BMI<35(group B) Mean preoperative BMI and body weight were 37.5±1.1 kg/m2, 109±13 kg and 33.3±1.2, 94.7±4.7 respectively. Mean follow-up for group A was 37±14 months (range 12-68) and for group B 39.6±12.5 months (range 12-65) Sample completed calibration table Results: The operation was completed laparoscopically in all patients with no peri-operative complications. Mean operative time and hospital stay were 46±6 min and 24 hrs respectively. Mean O-092 Less Favorable Outcomes For Laparoscopic Adjustable percentage of EWL at 1,2,3,4,5 years was 59%, 71%, 72%, 75%, Gastric Band Patients At A Tertiary Care Center With A Large 74% for group A and 68%, 73%, 72%, 78%, 79% for group B. In Geographic Referral Area group A slippage was found in 3.4%, erosion in 0.7% and failure in 10%. In group B slippage was found in 4.6%, erosion in 3.5% and PRESENTER: Peter Hallowell (University of Virginia) failure in 10%. Conclusion: In patients with low BMI, LAGB is a safe, easy to perform, reversible procedure, offering excellent long-term results. Co-Authors: Beth Turrentine1, Michael Miller1, Janet Dix1, Bruce With additional studies, demonstrating long-term effectiveness of Schirmer1 LAGB, it is reasonable to expect the selection criteria for bariatric surgery to be altered. 1. Surgery, University of Virginia, Charlottesville, VA, United States. O-094 The Gastric Band: Tricks And Tips To Achieve Satisfactory EWL% And Low Percentage Of Complications Background: Laparoscopic adjustable gastric banding (LAGB) is enjoying increasing popularity in the U.S. Few tertiary care centers with large geographic referral areas have reported medium term PRESENTER: Fabrizio Bellini (Bariatric and Metabolic outcome data for LAGB. We report results from our center, in which Surgery) many patients are referred from considerable distance, for outcomes after performance of LAGB. Methods: LAGB was performed using either the Lap-Band® or Co-Authors: Pietro Pizzi2, Michele Tarantini1 Realize® Band devices since 2004. Patient demographics, operative data, and follow-up results were recorded prospectively in our 1. Surgery, Bariatric and Metabolic Surgery, Desenzano (BS), Italy. institutional database for years 2004-9, and confirmed by the ACS 2. General surgery, Bariatric Surgery, Monza, Italy. National Surgery Quality Improvement Program Database for years 2005-8. Results: 303 patients with an average age of 45 years and an average Background: Laparoscopic Adjustable Gastric Band (LAGB) is the BMI of 45.2kg/m2 underwent LAGB between 2004 and 2009. most common bariatric restrictive procedure performed in the world. NSQIP captured 183 of these patients. Patients were mostly female Proponents of gastric band are claiming that LAGB should be the 79%, with considerable co-morbidities (21% ≥ 3 risk factors). HTN first choice in the treatment of obesity because of safety, reversibility, 56%, DM 34%, and OSA 26%. OR time averaged 81 min. There was short operative and in-hospital time. Opponents are claiming less 1 non-surgical related death at 30 days 0.33%. Morbidity by NSQIP weight loss and a high long-term complication rate. The purpose of data was 3.3%, and return to OR within 30 days 2.7%. Reoperations the study is to access that performing this operation in high volume have been for prolapse 2.6%, port problems 2.6%, erosion 0.66%, centres and using some surgical artifices we can have significant and 3 bands 1.0% were removed for poor weight loss. Average band results in weight loss and reduction of complications. adjustments in year 1 post-op were 3 and in year 2 only 1. %EWL at Methods: The records of all patients were reviewed retrospectively. 1 and 3 years averaged 33.4% and 34.1%. From 2001 to 2009 in two high volume bariatric centers we have Conclusion: Our patient population for LAGB had a high percentage performed 2834 LAGB. of co-morbidities. Virtually all procedures were done on an outpatient The minimal dissection of the gastro-frenic ligament, the” two-step” basis. Morbidity and mortality were not statistically higher than perigastric technique, the fixation of the band and the meticulous national norms. Excess weight loss at three years averaged only 34%. follow up, are the artifices followed in all the patients. Results: The results are analyzed according to EWL%, BMI, crural repair may be beneficial in alleviating the symptoms of GERD mortality, conversion to open surgery, intra-operative, short and long and reduce the need for re-operation. term complications, percentage of follow up. Methods: A retrospective analysis of randomly selected patients from Preoperative BMI was 42,6 for male and 41.9 for female a single surgeons practice was performed to investigate the effect of respectively. simple crural closure of an enlarged hiatus at the time of laparoscopic No intraoperative or postoperative deaths occurred. gastric banding in the morbidly obese. Those with a positive balloon Conversion rate: 2(0,07%), trocar site bleeding: 2. test (passage of a 10mL balloon through the hiatus) underwent Long term complications: slippage 128 (4,51%), intragastric simultaneous crural repair. Outcome measures were percentage body migration 13 (0,45%), trocars hernia 26 (0,91%), port or tube damage mass index loss (%BMIL), reflux symptoms and re-operation for 38 (1,34%), poor weight loss 192 (6,77%), band removal for slippage psychological intolerance 14 (0,49%). Follow up 87% at 60 months. Results: The groups were comparable with regards to %BMIL. Mean EWL at 60 months was 55,1% for female, 53.6% for male. Twelve month figures for LAGB only and for those with a crural Conclusion: The study shows that, using same simple technical repair were 37.3% (+/- 23.1%) and 39.0% (+/- 22.0%) respectively artifices in performing LAGB, we can achieve and maintain EWL > (p= 0.65). 54%, with a low rate of complications. The strict follow up is as well 63 had an enlarged hiatus tested at time of LAGB. 41 of these fundamental to acquire acceptable results. patients reported reflux pre-operatively, 36 of these had resolution of symptoms (85%, p<0.001). 13 of 63 patients who underwent LAGB alone reported pre-operative reflux. This had resolved in all but 3 O-095 Long-Term Results After Laparoscopic Gastric Banding patients post-operatively (77%), p=0.04). For Morbid Obesity. 15 Years Follow Up In A Single University Of those that required revisional surgery for slippage, 5 were from Unit. the LAGB only group (of 63) compared with only 1 from the LAGB + hiatal repair group (of 63) (p=0.09). This confers a reduction in risk PRESENTER: Konstantinos Arapis (Hôpital Bichat) of slippage requiring further surgery for those with hiatal repair (p<0.02). Conclusion: Comparable %BMIL can be achieved with LAGB with Co-Authors: Denis Chosidow1, Lara Ribeiro-Parmenti1, Pierre or without hiatal repair. Fournier1, Pantelis Antonakis1, Jean Pierre Marmuse1 There is overwhelming advantage in performing a hiatal repair at the time of LAGB in those who have a widened hiatus with regards to 1. Hôpital Bichat, Paris, France. resolution of reflux symptoms. Performing a hiatal repair appears to significantly reduce the risk of slippage requiring further operation. Background: Long-term follow-up data after laparoscopic adjustable gatric band (LAGB) are scarce, even though the procedure is one of the most commonly performed for morbid obesity. The aim of this study was to evaluate the long-term effects and failure rate of LAGB O-097 Lipid Profile In Morbidly Obese Patients Following Roux- in our institution, in a 15-year period En-Y Gastric Bypass Methods: Within 15 years, 915 patients underwent LAGB using either perigastric dissection (40.6%) or the pars flaccida approach PRESENTER: Rafal Paluszkiewicz (Medical University of (59.4%). Male to female ratio was 1 : 6.2, mean age was 38.5 (SE Warsaw) 0.34) and baseline median body mass index (BMI) was 44.2 (SD 6.2). Perioperative complication rate was 1.1% and procedure related mortality was 0.01%. Co-Authors: Piotr Kalinowski1, Piotr Remiszewski1, Janina Results: 907 eligible patients were followed-up for a median of 8.4 Bialobrzeska-Paluszkiewicz2, Hanna Zborowska3, Marek years (100,8 months, SD 36.1). Overall, 290 patients (31.9%) Krawczyk1 developed 335 late complications (1.2 per patient). LAGBs were removed during follow up in 276 cases (30,1%). In the group of patients with the band in-situ at 1, 5, 8 and 13 years postoperatively, 1. Department of General, Transplant and Liver Surgery, Medical median BMI values were 36 (SD 5.8), 35 (SD 6.4), 36.7 (SD 6.8), University of Warsaw, Warsaw, Poland. 36.2 (SD 7.1) and 36.3 (SD 7.5) respectively, while median EWL% 2. Metabolic Outpatient Clinic, Food and Nutrition Institute, Warsaw, values were 42.9% (SD 19.8), 47.6% (SD 22.9), 40.6% (SD 25.0), Poland. 46.0% (SD 6.1) and 44.1% (SD 28.1) respectively 3. Department of Laboratory Diagnostics, Medical University of Conclusion: LABG placement is a safe procedure, but results in Warsaw, Warsaw, Poland. overall <50% of EWL in both short and long term follow up and is accompanied by a significant reoperation rate. LAGB should no Background: Dyslipidemia is one of the most common problems of longer be considered as the procedure of choice for obesity bariatric patients. The purpose of the study was to evaluate course of changes in plasma lipid concentration and resolution of dyslipidemia O-096 Laparoscopic Adjustable Gastric Banding. Is Crural after RYGB. Repair Necessary? Methods: During 2004-2009, 104 patients underwent RYGB. Mean BMI was 49.8±7.5. Plasma lipids were measured before surgery and 3, 6, 9 and 12 months after. Follow-up was at least 12 months. PRESENTER: Harry Frydenberg (Epworth Centre for Bariatric Diagnosis of dyslipidemia (atherogenic dyslipidemia or Surgery, Melbourne, VIC, Australia.) hipercholesterolemia) was based on the criteria of the European Society of Cardiology (ESC). Results: Atherogenic dyslipidemia was initially diagnosed in 19.2% Background: The role of band placement in those with and hipercholesterolemia in 34.6% patients. Mean BMI after 12 gastroeosophageal reflux disease (GERD) and crural laxity is months was 33.6±5.8 and excess weight loss was 66.8±18.3%. Lipid controversial. In patients with reflux and/or a widened hiatus who are levels improved and diagnoses of dyslipidemia resolved in significant undergoing adjustable laparoscopic gastric banding (LAGB), simple group of patients as shown in table 1. All lipid fractions decreased significantly during first 3 months. After 3 months TC and LDL-C remained at such level with no significant changes, TG continued to independent of this, quick resolution of type-2 diabetes. The aim of decrease and HDL-C increased until 12 month. the present study was to identify mechanisms potentially involved in Conclusion: Lipid profile improves significantly after RYGB in the effects of RYGBP surgery on obesity and diabetes in the jejunal patients with morbid obesity. TC and LDL-C fractions improve mucosa of the roux-limb. mainly in the early period after RYGB while TG and HDL-C Methods: Samples were retrieved from 7 patients from the jejunal improve more steadily as patients loose weight. Prevalence of mucosa peroperatively, and by gastroscopy 6-months after surgery. diagnoses of hipercholesterolemia and atherogenic dylipidemia also The samples were analyzed for global protein expression by 2- decreases. Dimensional gel electrophoresis and mass spectrometry. The major protein regulations were confirmed by Western blotting. Results: Analysis revealed 27 protein spots that were regulated Table 1. Lipid profile and prevalence of dyslipidemias. similarly in all patients. These corresponded to 11 different proteins, identified by mass spectrometry. Among these were structural O-098 Surgical Morbidity Associated With Laparoscopic cytoskeleton proteins such as cytokeratin (ck) 8, ck 20, collagen Bariatric Surgery In Type 1 And Type 2 Diabetics alpha 1, and vinculin, which were all upregulated. We also found changed expression of proteins with metabolic functions. Conclusion: The changes in protein expression of structural and PRESENTER: Catherine Bradshaw (Imperial College metabolic proteins may correspond to an altered barrier function and Healthcare) changed metabolism of the jejunal mucosa of the roux-limb after RYGBP surgery. Co-Authors: William Collins1, Sherif Hakky1, Ahmed R. Ahmed1 O-100 Prolonged Remission Of Type 2 Diabetes Mellitus In Morbid Obese Patients With Roux-And-Y Gastric Bypass 1. Imperial College Healthcare, London, United Kingdom.

PRESENTER: Manoel Galvao Neto (Gastro Obeso Center) Background: Diabetes Mellitus is considered to be a risk factor for adverse surgical outcomes and post-operative complications. We compared outcomes between type 1, type 2 diabetic and non-diabetic Co-Authors: Daniel C. Lins1, Josemberg M. Campos1, Luis F. patients undergoing laparoscopic adjustable gastric banding (LAGB), Evangelista1, Almino C. Ramos2, Alvaro Antonio B. Ferraz1 laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). Methods: Retrospective study of 407 patients undergoing 1. Surgery, Federal University of Pernambuco, Recife, Pernambuco, laparoscopic bariatric surgery between December 2007 and January Brazil. 2010. Outcomes included length of stay, complication rates, re- 2. Gastro Obeso Center, Sao Paulo, Sao Paulo, Brazil. operation rates and mortality. Results: Of 407 patients, 125 (31%) were diabetic. Diabetic patients Background: Type 2 diabetes mellitus (T2DM) surgical treatment is a underwent 88 LRYGBs, 29 LSGs and 8 LAGBs. There was 1 death: recent issue and data of it long lasting effect are still needed to make a type 1 diabetic following LRYGB. Average length of stay was 2.1 clear pre and post operative variables. The author‟s presents a series in the diabetics and 1.8 in the non-diabetics. Complication rates and of morbid obese T2DM (NIH criteria) subjects treated with RYGB re-operation rates were, respectively, 12.1% and 7.4% in the non- followed at long term and its results diabetics, 16.8% and 10.4% in the type 2 diabetics and, 33% and 0% Methods: 107 morbid obese T2DM patients submitted to RYGB from in the type 1 diabetics (Table 1). No statistical significance was 2001 to 2006 at Federal University of Pernambuco (Recife, Brazil) observed between type 2 diabetic and non-diabetic groups in any of had their charts reviewed under IRB approved protocol. Pre and post- the outcome measures. op variables evaluated regarding T2DM control were diet, use of oral Conclusion: There is no significant difference in post-operative medicine and/or insulin. Remission was define as; FG < 130mg/dl morbidity between type 2 diabetic and non-diabetic patients with no anti-diabetic drugs and non-remission defined as FG> undergoing LRYGB, LSG or LAGB. This suggests type 2 diabetes is 130mg/dl and/or use of anti-diabetic drugs not a significant risk factor for adverse surgical outcome following Results: At 5 year follow-up prolonged remission was obtained in 98 laparoscopic bariatric surgery. However a high morbidity was (91,6%) patients with a mean of 73%EWL (no differences on gender observed in type 1 diabetics suggesting this may be a significant risk and age). From the baseline, oral drugs and insulin use drops from 30 factor although further study in this group of patients is needed. to 5.6% and from 9 to 2.8% respectively. Clinical variables that predicting remission X non-remission were; time from T2DM O-099 Proteomic Analysis Of The Jejunal Mucosa Of The diagnostic with 3.4 X 8.2y (p=0,016), use of insulin (p<0,001) and Roux-Limb Per And Post Roux-En-Y Gastric Bypass Surgery BMI % decrease 43,7% X 33,5% (p=0,026). Other variables like Reveals Specific Regulation Of Cytoskeleton Proteins And weight regain, use of silastic ring at gastroplasty and time of insulin Indicates A Changed Metabolic Activity Of The Small Intestine. use were not statistically significant at T2DM remission Conclusion: Prolonged remission can be obtained in morbid obese T2DM patients surgically treated with RYGB and some of its PRESENTER: Erik Elias (Sahlgrenska University Hospital) predictable variables could be identified Co-Authors: Emma Spak1, Anna Casselbrant1, Per Björklund1, Lars Fändriks1, Ville Wallenius1 O-101 Effect Of Roux-En-Y Gastric Bypass On Metabolic Syndrome 1. Gastrosurgical research, Sahlgrenska University Hospital, Gothenburg, Sweden. PRESENTER: Piotr Kalinowski (Medical University of Warsaw)

Background: Bariatric surgery is currently the most effective treatment of obesity. Roux-en-Y Gastric Bypass (RYGBP) has been Co-Authors: Rafal Paluszkiewicz1, Piotr Remiszewski1, Janina shown to result in a substantial and long-term weight loss and Bialobrzeska-Paluszkiewicz2, Marek Krawczyk1 medication and 93% with medication; 5) mean current FPG is 93 mg/dl and HbA1c is 6%; and 6) there were no severe complications or deaths. 1. Department of General, Transplant and Liver Surgery, Medical Conclusion: RYGB is safety and effective option in the treatment of University of Warsaw, Warsaw, Poland. uncompensated T2DM associated to Class I obesity. 2. Metabolic Outpatient Clinic, Food and Nutrition Institute, Warsaw, Poland. O-103 Laparoscopic Roux-En-Y Gastric Bypass For The Background: The purpose of this study was to assess the effect of Treatment Of Type 2 Diabetes In Patients With Bmi Below 35 Roux-en-Y Gastric Bypass (RYGB) on metabolic syndrome in morbidly obese patients. The International Diabetes Federation (IDF) PRESENTER: Camilo Boza (Pontificia Universidad Católica de criteria used to define metabolic syndrome include abdominal Chile) obesity, impaired fasting glycemia (IFG) or type 2 diabetes mellitus (DM), hypertension (HTN), elevated triglycerides (TG) and low high density lipoprotein cholesterol (HDL-C). Co-Authors: Cristian Gamboa1, German Viscido1, Ricardo Funke1, Methods: From 2004 to 2009, RYGB was performed in 104 patients. Pablo Becerra1, Gustavo Perez1, Fernando Crovari1, Luis Ibanez1 They were evaluated before treatment and at 3, 6, 9 and 12 months after surgery. The follow-up was at least 12 months. 1. Pontificia Universidad Católica de Chile, Santiago, Chile. Results: Mean BMI was 49.8±7.5. Metabolic syndrome was present in 66 (64%) patients. Among patients with metabolic syndrome 5 components were present in 7 (11%), 4 in 30 (45%) and 3 in 29 Background: Traditional eligibility for bariatric surgery stands for (44%) patients. The prevalence of the components of metabolic patients with a BMI>40 or BMI>35 with comorbidities. The aim of syndrome is shown in table 1. After 12 months 9 (14%) patients this study was to analyze our experience on the treatment of type 2 fulfilled the IDF criteria but all of them had only 3 components of diabetes with Laparoscopic Roux-en-Y gastric bypass in patients with metabolic syndrome. At 12 months there was no significant BMI <35 kg/m2. difference between the patients with metabolic syndrome before the Methods: We review our prospective electronic database for all type surgery and the patients without metabolic syndrome in mean BMI 2 diabetes patients undergoing LRYGB with a BMI between 30-35 (33.2 vs 34.3; p>0,05) and percent of excess weight loss (69.3% vs kg/m2 from July 2002 to January 2010. We assessed surgical results, 62.3%; p>0,05). % excess weight loss (%EWL) and metabolic control. Conclusion: The prevalence of metabolic syndrome decreases Results: During this period 80 patients (64.6% female) underwent significantly after RYGB and the patients achieve adequate weight LRYGB for the treatment of T2DM. Mean age was 47.7±8.9 years. loss. RYGB may be especially beneficial in this group of patients Preoperative weight and BMI was 90.3±12.0kg and 33.0±1.4 kg/m2 thanks to its favorable metabolic characteristics. (30-34.9). Other preoperative comorbidities were arterial hypertension (HTN) 67.1% and dyslipidemia (DLP) 62%. No conversion nor reoperation to open surgery was required. The most O-102 Gastric Bypass In The Treatment Of Type 2 Diabetes In common postoperative complication was gastro-jejunal stenosis Patients With A BMI Of 30 To 35 Kg/M2 (12.3%) . There was no mortality nor leaks. Median follow-up was 16 months (mean 23,3±20,5). Excess weight loss (%EWL) was PRESENTER: Manoel Galvao Neto (Gastro Obeso Center) 93.8±25.4% at 6 months, 103.2±29.4% at 1 year and 112.3±30.5% at 2 years. Resolution at 1 year follow-up for T2D was 76.5% , for HTN: 46.7% and for DLP was 80.1. Hemoglobin A1C dropped from Co-Authors: Vladimir Curvelo T. de Sa1, Josemberg M. Campos1, 7.7±1.7 to 5.9±0.9 mg/dl at 12 months. Luis F. Evangelista1, Almino C. Ramos2, Alvaro Antonio B. Ferraz1 Conclusion: LRYGB has proven to be a safe and effective treatment for T2DM at 12 months. 1. Surgery, Federal University of Pernambuco, Recife, Pernambuco, Brazil. O-104 Metabolic Bypass. Initial Experience With Roux-And-Y 2. Gastro Obeso Center, Sao Paulo, Sao Paulo, Brazil. Gastric Bypass On Type 2 Diabetes Treatments For Non-Morbid Obese Patients Background: Type 2 diabetes mellitus (T2DM) and class I obesity, which are pandemics of considerable socioeconomic importance, PRESENTER: Almino Ramos (Gastro Obeso Center) require new treatment modalities due to inadequate control through normal clinical conduct. The aim of the present study was to assess the efficacy and safety of Co-Authors: Manoel P. Galvao Neto1, Manoela Galvao1, Andrey Roux-Y gastric bypass (RYGB) in the control of T2DM in patients Carlo1, Edwin Canseco1, Thales D. Galvao1, Luis F. Evangelista2, with a BMI of 30 to 35 kg/m2. Alvaro Ferraz2, Josemberg M. Campos2 Methods: An observational, retrospective study was carried out at the Universidade Federal de Pernambuco - Brazil. Between 2002 and 1. Surgery, Gastro Obeso Center, Sao Paulo, Sao Paulo, Brazil. 2008, 27 patients were submitted to RYGB for the treatment of 2. Surgery, Federal University of Pernambuco, Recife, Pernambuco, uncontrolled T2DM, with a mean follow-up period of 20 months. An Brazil. assessment was performed of the complete resolution of T2DM [HbA1c < 6% / fasting plasma glucose (FPG) < 100 mg/dL / no diabetes medication] and glycemic Background: At least 2 metanalysis points bariatric surgery as long control. The ethics committee of university approved the study. lasting control over T2DM on morbid obese patients. One question is Results: RYGB led to the following results: 1) 23% weight reduction if it can works in non-morbid obese patients. Authors present initial (p<0.001), BMI stabilized at 25.6 Kg/m2 in a mean of 12 month; 2) results of a study with the Simplified Metabolic Laparoscopic Roux- 46% reduction in glycemia and 27% reduction in HbA1c (p<0.001); en-Y Gastric Bypass (SMGB) to treat T2DM 3)100% improvement in glycemia and 48% resolution of T2DM; 4) Methods: Prospective study since Jan-2008 to Feb-2010 under signed glycemic control was 74% without informed consent and local ethics committee approval. Inclusion criteria: BMI 25-35, Age 18-60y, T2DM Hx 2-12y, Oral med and/or University Hospital) insulin use, HbA1c 7,0-12,0 and C-peptide at any level. Casuistic is over 147 subjects, 78 (53.1%) men, 34-60y (m=46.9y), BMI 26-33 (m=29.1), mean T2DM diagnosis, HbA1c and C-Peptide of 4.9y (2- Co-Authors: Enrique Lanzarini1, Attila Csendes1, Juan Carlos 12y), 8.7 (7.5-12y), 1.9 (0.4-6.0) respectively and 15p using insulin. Molina1, Italo Braghetto1, Luis Gutierrez1 SMGB technique consists on creating a 8-10cm gastric pouch; small bowel counted from Treitz ligament up to ileo-cecal valve marked 1. Department of Surgery University Hospital, Santiago, Chile. each 100cm; first 2 fifths are considered as jejunum and an antecolic looped stapled (non-calibrated) anastomosis is constructed. Jejunostomy created with the alimentary limb on the omega loop and Background: In severe obese patients, Roux-en-Y Gastric Bypass then converted in Roux limb by stapling the double-loop (RYGBP) produces a specific effect on type 2 diabetes mellitus Results: T2DM control (no med + glucose control) has been achieved (T2DM), demonstrating early improvements in glycemic control. in 124 (84.3%) and 23 patients are on oral medication only Objective: Analyze the metabolic and glycemic control parameters (Metformin) . HbA1c was at 6.4(5.4-7.2) in 31p at 18m. before and after RYGBP in T2DM patients with a Body Mass Index Complications were 1 G-J fistula and 3 G-J stenosis with no mortality (BMI) over 35. Conclusion: SMGB seems to be a therapeutic alternative to T2DM Methods: Revision of clinical files of 89 patients with T2DM and control and treatment. Further randomized and controlled long-term BMI 35 who underwent RYGBP between 2000 and 2008. Controls studies should be performed were performed preoperatively and at 3, 6, 12, 36, 60 and 72 months. The t-student test was used to analyze data. Results: The mean evolution time of T2DM was 4,8 years. The O-105 Late Follow-Up Of Roux-Em-Y Gastric Bypass In Patients average follow up was 58,6 months, with a maximum of 107. BMI With Severe Obesity And Type 2 Diabetes Mellitus: Influence Of decreased from 43,9 to 30,6 kg/mt2 at 6 months and without Weight Regain On Diabetes Control. significant changes during the follow up. Mean fasting blood glucose levels were normalized at 6 months, decreasing from 141 to 88 PRESENTER: Manoel Galvao Neto (Gastro Obeso Center) mg/dl, and remained stable during follow up. The tendency of mean glycosylated hemoglobin levels was similar, descending from 7,2 to 5,3 mg/dl at 5 years. The mean insulin level and HOMA score Co-Authors: Jose Guido C. Araujo Junior1, Josemberg M. Campos1, decreased significantly over time, from 28,3 and 9,9 in the Luis F. Evangelista, Almino C. Ramos2, Alvaro Antonio B. Ferraz1 preoperatory control, to and 6 and 1,5 at 3 years, respectively. Levels of total Cholesterol, LDL and triglycerids decreased significatively, but HDL measurements stayed without changes during the follow up. 1. Surgery, Federal University of Pernambuco, Recife, Pernambuco, Conclusion: RYGBP is an effective therapy which achieves stable Brazil. long term results controlling glycemic and metabolic parameters in 2. Gastro Obeso Center, Sao Paulo, Pernambuco, Brazil. patients with T2DM and a BMI over 35.

Background: Introduction: Roux-em-Y gastric bypass (RYGB) produces glycemic control in type 2 diabetic patients. Weight regain O-107 Three-Dimensional Stomach Analysis With Computed is not infrequent though, affecting 10-20% on late follow-up. The Tomography Gives Rise To Sleeve Dilation And Thoracic influence of weight regain on glycemic control has not yet been well Migration After Laparoscopic Sleeve Gastrectomy established. Objective: to evaluate the influence of weight regain on glycemic control in type 2 diabetes mellitus after RYGB. PRESENTER: W. Karcz (University of Freiburg) Methods: a longitudinal (retrospective + prospective) study was conducted. Patients were selected for two groups: group 1 (n=15): significant weight regain and BMI > 35kg/m2 on late follow-up and Co-Authors: Tobias Baumann2, Jodok Grueneberger1, Simon group 2 (n=30): patients without significant weight regain and BMI < Kuesters1, Goran Marjanovic1, Ulrich T. Hopt1, Mathias Langer2, 30kg/m2 on late follow-up. Glycemic control was evaluated on three periods: preoperative, postoperative T1 (<24 months) and T2 (>36 1. Department of general and Visceral Surgery, University of months, prospective evaluation). Freiburg, Freiburg, Germany. Results: Weigh regain patients presented a mean 44.5% excess BMI 2. Dept. of Radiology, University of Freiburg, Freiburg, Germany. loss, while control patients presented a mean 89.8% excess BMI loss (p<0.05). Significant reductions in fasting glucose and pharmacotherapy were observed on both groups. There were no Background: Data on the detailed geometrical and quantitative significant differences on fasting glucose, oral glucose tolerance test, analysis of the anatomy after LSG are missing. HbA1c, and diabetes resolution after RYGB between groups 1 and 2 Methods: Thirty-two multi-slice computed tomography (MSCT) on late follow-up. Weight regain patients presented on late follow-up datasets acquired in 27 patients (22 female, 5 with significant increases in fasting insulin, insulin resistance and male) with a dedicated examination protocol and post-processing in beta cell function, when compared to control patients. Complete patients after LSG were evaluated diabetes remission was achieved in 73.3% of weight regain patients for gastric volume, stomach length, sleeve length, antral length, and in 80% control patients (p>0,05). stapler line length and maximum crosssectional Conclusion: Weight regain does not significantly influence the sleeve area. Obtained data were compared to time after surgery, resolution of type 2 diabetes mellitus after RYGB on a mean follow- weight-loss and the occurrence of postsurgical regurgitation. up of 64,8 months. Results: Mean gastric volume was 186.5 ± 88.4 and correlated significantly with the time interval after surgery. Sleeve sizes of 105.3 ± 30.2ml during early follow-up confirmed O-106 Metabolic Outcomes Of Roux-En-Y Gastric Bypass, In correct primary sizing of the sleeve with marked dilation to 196.8 ± Type 2 Diabetes Patients With Body Mass Index Over 35. Long 84.3 ml being recognised in patients with a follow-up of 6 months Term Follow Up. and longer (p = 0.038). Sleeve area and stapler line length were also positively correlated with time after surgery. No correlation was PRESENTER: Hanns Lembach (Department of Surgery found between gastric volume and excess weight loss. In 10 patients an Background: Since the proposal of laparoscopic sleeve gastrectomy intrathoracic migration of the stapler line could be noted with 4 of (LSG) as a primary bariatric procedure it has becoming popular due these patients developing persistent regurgitation after LSG, whereas to reduced surgical time; relatively surgical less complexity and good regurgitation was only present in 2 of 17 patients without sleeve resolutions on comorbidities. There‟s still some technical controversy herniation. regarding LSG as size of bougie; where to start the stapling and the Conclusion: Multi-slice computed tomography allows for a need of oversuture. Authors present the results of LSG using 32 Fr comprehensive, quantitative evaluation of the anatomy calibration tube and antrectomy. using 22 Fr calibration tube and after LSG providing new insights in the process of sleeve dilation. antrectomy. Intrathoracic migration of the stapler Methods: A prospective single arm study assessment was made on line could be identified as a possible cause of persistent regurgitation. 192 consecutive morbidly obese patients (NIH criteria). BMI 35-50 (m=42) who underwent LSG using the following technique: division of the vascular supply of the greater curvature followed by the linear O-108 Dynamic MRI Reveals Gastric Motility After stapling beginning at 1 – 2 cm from the pylorus performing Laparoscopic Sleeve Gastrectomy antrectomy tightly over a 32 Fr bougie as a guide to perform the sleeve; reinforcement the staple line with absorbable running suture PRESENTER: W. Karcz (University Hospital Freiburg) Results: Patients follow-up varied from 3-18 months. Intraoperative complication happened as 4 patients with staple line disruption on the first cartridge close to the pylorus resolved by manual suturing. Co-Authors: Tobias Baumann1, Jodok Grueneberger2, Simon Median %EWL in 1-year follow-up was 82%. Mean hospital length Kuesters2, Mathias Langer1, Ulrich T. Hopt2 of stay was 3 days (1,5 – 12 days). Hiccup occurred in the first days in 4 patients (2 %) improving in up to the first week. Nausea and 1. Department of Radiology, University Hospital Freiburg, Freiburg, vomit occurred in the first 2 -3 days after the procedure in 42 patients Germany. (21 %) 2. Department of General and Visceral Surgery, University Hospital Conclusion: LSG calibrated to 32 Fr with antrectomy seems to be Freiburg, Freiburg, Germany. effective and safe bariatric procedure with good % EWL on short term. Additional prospective randomized comparative trials are still needed. Background: Laparoscopic sleeve gastrectomy (LSG) is generally considered a restrictive procedure. The exact mechanisms of weight- loss after LSG, however, have yet to be defined. To address this O-110 Intraoperative Evaluation Of Gastric Thickness During question we analyzed the stomach motility before and after LSG by Laparoscopic Sleeve Gastrectomy means of dynamic MRI Methods: Five female patients with a mean BMI of 51.6 received PRESENTER: Francesca Lirosi (University College London MRI one day before LSG and six days and six months after LSG. Hospital) Dynamic steady-state free precession sequences were used to analyze the gastric motility after ingestions of 500ml water with a temporal resolution of 0.86s. Axial image stacks were also repeatedly acquired Co-Authors: Cynthia M. Borg1, Mohammed Elkalaawy1, James to determine the gastric fluid volume over time. Holding2, Marco Adamo1 Results: Mean EBMIL was 60.6% after six months. Dynamic analysis showed that antral propulsive peristalsis was preserved 1. Bariatric Surgery, University College London Hospital, London, immediately after surgery and during follow up, but fold speed United Kingdom. increased significantly from 2.7mm/s before LSG to 4.4mm/s after 2. Department of Anesthesia, University College London, London, six months. The sleeve itself remained completely without peristalsis United Kingdom. in three patients and showed only uncoordinated waves in two patients. Consequently the fluid volume in the sleeve remained almost constant in three patients, whereas the antrum showed Background: Laparoscopic sleeve gastrectomy involves stapling accelerated transport with the emptying half-time decreasing from alongside gastric Magenstrasse. According to specimen studies 16.5 to 7.9min. stomach thickness in females ranges from 3,1mm to 1,6mm distal to Conclusion: The proximal part of the stomach remains almost proximal. Stapling devices are recommended for maximum tissue completely still after LSG, whereas antral emptying and fold speed height (when compressed) of 2mm. Therefore tissue compression increase significantly after surgery. New concepts on weight loss must be responsible for staple line formation. In order to address after LSG will have to consider these novel findings by MRI. tissue height prior to stapling we recorded intraoperative in-vivo measurement of gastric thickness by ultrasound Methods: Measurements were carried out in 10 consecutive LSG O-109 Calibrated 32 Fr Sleeve Gastrectomy With Antrectomy. female patients (average BMI of 49). LSG employed 32Ch-Bougie Early Results. placed on lesser curve. Each LSG required five firings of Echelon

60mm stapler (Ethicon-Endosurgery) loaded with green cartridges (2mm staples) for first two antral firings and gold cartridges (1.8mm PRESENTER: Almino Ramos (Gastro Obeso Center) staples) for remaining three. Staple line reinforcement (Seamguard- Gore) was employed, adding 0.5mm thickness. To measure gastric walls diameter, a 7.5Mhz laparoscopic ultrasound probe was placed Co-Authors: Manoel Galvao1, Manoela Galvao1, Josemberg M. transversally to the stapler. Measurements were taken from anterior Campos2, Luis F. Evangelista2, Thales D. Galvao2, Mariano and posterior gastric wall just before each firing (but the last) at the Menezes1 medial edges of the stapler. Results: In-vivo ultrasonic measurements of gastric walls were 1. Surgery, Gastro Obeso Center, Sao Paulo, Sao Paulo, Brazil. consistent and reproducible within the group. Average total thickness 2. Bariatric and metabolic Surgery, Federal University of recorded was 2.2(±0.1), 2.2(±0.1), 2.0(±0.1) and 2.0(±0.1) mm Pernambuco, Recife, Pernambuco, Brazil. starting from the antrum. All LSG were uneventful (average operative time 80 minutes) with no complications or readmissions. Conclusion: Intraoperative ultrasonic measurement of gastric complication occurs almost invariably in a “critical area” on the thickness is a reliable and reproducible technique during LSG. Total uppermost part of the suture line at the esophago-gastric junction. In thickness from gastric walls and buttressing material exceeds this area, anatomical studies (Testut, 1932) demonstrated a transition maximum staples height, so tissue compression is essential for staple from esophageal to gastric blood supply with possible “critical zone” line formation. of vascularisation. Aim: To evaluate leak rate in our series of SG and to propose a technique to prevent this complication. O-111 Laparoscopic Sleeve Gastrectomy-Early Post-Operative Methods: From October 2002 to November 2009, 335 patients Complications underwent SG. No routine reinforcement was performed in first 100 cases (Group 1). In 200 cases reinforcement was performed routinely PRESENTER: David Hazzan (Carmel Medical Center) (Group 2). In the last 35 cases the resection line was carried out avoiding the “critical area” by resecting the fundus 1.5 cm from the angle of His. Reinforcement was performed by introflecting the Co-Authors: Andrei Keidar2, Shiloni Eitan1, Naama Kafri4, Orit staple-line for the first 3 cm at the upper and by simple oversewing Nattiv5, Chaya Schweiger5, Nissim Geron3 suture in the remaining portion (Group 3). Results: Staple-line leaks occurred in 9 patients (2.6%, Mean BMI 1. Surgery B, Carmel Medical Center, Haifa, Israel. 52.5; mean age 41.6 years). Four cases in Group 1 (4%), 5 in Group 2 2. Surgery, Hadassah University Hospital, Jerusalem, Israel. (1.6%). No leaks were registered in Group 3. Non-operative 3. Surgery, Baruch Padeh Medical Center, Tiberiades, Israel. management (TPN, PPI and antibiotics) was adopted in all cases but 4. Bariatric Clinic, Lin Medical Center, Haifa, Israel. one for persistence of the leak and absolute non compliance of the 5. Bariatric Surgery Clinic, Hadassah University Hospital, Jerusalem, patient. Israel. Conclusion: Staple line leak is a major problem in SG. Impaired vascularisation was hypothised as pathogenetic factor. On this basis the results of a series of 35 cases seem to be promising as a solution. Background: Laparoscopic Sleeve gastrectomy (LSG)is becoming a common technique for the treatment of morbid obesity.There is a paucity of data regarding the early postoperative complications of O-113 Stapler Line Leakage Following Sleeve Gasrectomy: this operation. The aim of the study is to review and report the 30 Prolonged Course Despite Different Treatments days post-operative complication rate in our institutions. Methods: All patients who underwent LSG in our institutions were PRESENTER: Subhi Abu-Abeid (Tel Aviv Medical Center) included. The data was obtained from a prospective data base from each hospital. Background: Sleeve gastrectomy is gaining more and more 371 patients were included.248 female and 123 male. acceptance in Baiatric surgery and comprise 8% of operation in the Mean BMI was 45.2 Kg/m2 (29-64).Mean Age was 42 years (13-67). wetern world . 313(84.3%) patients underwent primary sleeve and 58(15.7%) Stapler line leakage is of major concern in these operations despite patients,revisional surgery.45(77%) patients after LAGB and various treatment methodsincluding stenting ' clipping ' drainaige and 13(23%) patients after SRVG. glue injection Results: Thirty seven patients had 39(10.5%) complications. Methods: 17 patients developed stapler line leakage following sleeve 13(3.5%) patients were reoperated. 4(29.8%) patients underwent gastrectomy :in 16 the leakage was in the G-E junction and in one laparotomy and 9(69.2%)laparoscopy.The complication rate was patient low in the stapler line . 7 patients were stented '2 were treated higher in the revisional group.(34.2 % vs 5.7%).P<0.005.Patients with glue' 8 patients were reoperated / all patients recieved broad after SRVG had 61.2 % complication rate.The most common spectrum antibiotics togather with gastric drainage complications included:subphrenic abscesses, intraabdominal Results: The first group with the glue needed 3 sessions of bleeding and severe esophagitis. endoscopic treatment '5 of the stented groupe needed further The re-operation rate was higher in the revisional surgery group, 10.2 endoscopy to relocalize the stent 'and the operated group had % vs 2.2% in the primary surgery group.P<0.005. prolonged post operative course .one patient was operated for the Conclusion: Laparoscopic Sleeve Gastrectomy is a safe procedure third time with reasonable major morbidity. Conclusion: Despite the different treatment options for leakage Revisional surgery increased exponentially the rate of post-operative following sleeve gastrectomy ' the cours is prolonged and surgery complications. may be required / Sleeve gastrectomy after SRVG has the higher incidence of morbidity O-114 Positioning Of Bariatric Surgery In Germany – Results Of The Nationwide Survey On Bariatric Surgery 2005 - O-112 Staple-Line Leak After Sleeve Gastrectomy: Pathogenetic 2009 Hypothesis And Possible Prevention PRESENTER: Christine Stroh (Otto von Guericke Universität PRESENTER: Nicola Basso (University "Sapienza") Magdeburg)

Co-Authors: Giovanni Casella1, Emanuele Soricelli1, Benedetto Co-Authors: Christine Stroh1, Christine Stroh2 Calì1, Francesca Abbatini1, Giorgio Alessandri1 1. Surgery, SRH Wald-Klinikum Gera, Gera, Germany. 1. Surgical Medical Department for Digestive Diseases, University 2. Surgery, Otto von Guericke Universität Magdeburg, Magdeburg, "Sapienza", Rome, Italy. Germany.

Background: The most feared and life-threatening complication of Background: Most studies on bariatric surgery outcomes are Laparoscopic Sleeve Gastrectomy (SG) is staple-line leak. This performed as clinical trials or reflect the clinical experience in single centres. The status of bariatric surgery in Germany has been O-116 4-Year Results Of Laparoscopic Sleeve Gastrectomy In 26 examined since January 1st, 2005 with the cooperation of clinics and Patients After Failed Adjustable Gastric Banding hospitals at the Institute of Quality Assurance in Surgery at the Otto- von-Guericke University of Magdeburg (Germany). PRESENTER: Konstantinos Arapis (Hôpital Bichat) Methods: In this prospective multicenter observational study, the data obtained for all primary bariatric procedures, including all repeated operations, performed on consecutive patients with morbid obesity at Co-Authors: Pierre Fournier1, Denis Chosidow1, Lara Ribeiro- participating hospitals from 2005 - 2009 were prospectively collected Parmenti1, Marina Kousouri1, Jean Pierre Marmuse1 using an Internet online data registry. Perioperative characteristics such as the spectrum of diagnostic measurements, type of surgical procedures, and short- and long-term outcomes were investigated. 1. Surgery, Hôpital Bichat, Paris, France. Results: During the study period more than 9500 surgical procedures were performed. Until 2007 gastric banding (GB) was the most Background: Laparoscopic sleeve gastrectomy (LSG) has only frequently performed operation, followed by the Roux-en-Y-Gastric recently emerged as an alternative for the treatmenof morbid obesity Bypass (RYGBP). In was carried out in 36.1 % of all bariatric after failed laparoscopic adjustable gastric band (LAGB). The aim of procedures. Among all patients, 74.4 % were female. The mean BMI our study was to evaluate the results of LSG as a revisional procedure was 48.1 kg/mxm in 2008. Follow-up data after 24 months were of failed LAGB. available for 1.707 patients operated in 2005 and 2006. The mortality Methods: 26 patients (male to female ratio 1:6,5) with a mean age of was 0.2 % (overall). 35,4 years (SE:8,3), underwent LSG at a median of 4,5 years Conclusion: As indicated by the worldwide trend, there is an ongoing (SD:1,3) after failed LAGB. Preoperative median body mass index change from GB to Sleeve Gastrectomy (SG) and malabsorptive (BMI) was 38,5 (SD 4,6). The adjustable band had been removed in 7 procedures. BMI of German bariatric surgical patients is substantially cases prior to the LSG. A standard LSG was performed with an higher than patients from most other countries. There were no endostapler over a 34-French bougie differences in overall outcomes during follow-up when compared Results: The median operative time was 95 minutes (SD 24,3). with published studies. Perioperative complications occured in 4 patients (15,3%). Our patients were followed-up for a median of 36 months (SD:7,4). Long- term complications occured in 1 patients (3,8%%). Reoperation after O-115 Laparoscopic Sleeve Gastrectomy As A Revisional LSG was mandatory in 4 patients (15,3%) due to weight loss. In 2 Procedure For Failed Adjustable Gastric Banding Or Vertical and 4 years after the operation BMI was 36,6kg/m2 (SD: 4,3) and Banded Gastroplasty 32,4kg/m2 (SD:4,2) respectively, while the percentage of excess weight loss (%EWL) was 35,3% (SD: 3,2) and 42,4% (SD:2,5) PRESENTER: Nicola Basso (University "Sapienza") respectively. Conclusion: LSG seems to be effective as revisional procedure for 1 1 Co-Authors: Emanuele Soricelli , Giovanni Casella , Mario failed LAGB. Larger series are needed to further evaluate and 1 1 1 Rizzello , Benedetto Calì , Francesca Abbatini confirm these promising results

1. Surgical Medical Department for digestive Diseaes, University Gastric Plication To Improve The Results Of Laparoscopic "Sapienza", Rome, Italy. Gastric Banding

Background: Laparoscopic Adjustable Gastric Banding (LAGB) PRESENTER: Sami Ahmad (Gastriccenter/Klinik Rotes Kreutz) and Vertical Banded Gastroplasty (VBG) are commonly performed bariatric procedures. However a failure rate up to 40-50% in a long term follow-up has been reported. Laparoscopic Sleeve Gastrectomy Co-Authors: Sufian Ahmad1, Ralf Matkowitz1 (LSG) is considered an effective multipurpose operation for morbid obesity and the aim of the study is to evaluate its effectiveness and safety as a revisional procedure for failed LAGB or VBG. 1. Obesity Center, Gastriccenter/Klinik Rotes Kreutz, Stuttgart, Methods: From May 2004, 21 patients (7 males and 14 females) Germany. with a mean age of 41.2± 7.4 years underwent revisional LSG, 18 after LAGB, 3 after VBG. The mean BMI before LAGB/VBG was Background: Laparoscopic gastric banding (LAGB) is a well 47.3 ± 4.5 kg/m2. The average interval between LAGB/VBG and established procedure to treat morbid obesity and to improve its revisional LSG was 66.8 ± 50.1 months. Before conversion, the comorbidity, Gastric banding entered into widespread use in the mid mean BMI was 46.4 ± 9.4 kg/m2. One step revision procedure was 1990s. Hallberg and Forsell, as well as Kuzmak worked on separate done in 19 patients (90.5%). A two-steps procedure, first continents to develop the clinical application of adjustable gastric laparoscopic band removal and second LSG, was performed in two bands in the early 1980s. Several technique were applied to decrease patients (9.5%) with eroded band in the gastric cavity. the complication of the gastric band and to improve the weight loss. Results: The mean operative time was 125 minutes (range 85-190 In our comparative study we observed the results of two different min). No conversion to open surgery was required. Mortality was techniques of LAGB for at least one year. nil. Three post-operative complications (14.2%) occurred in two Methods: we randomized 100 patients who attended our clinic from patients: two bleedings and a leak. After a mean follow-up of 15.6 ± Oct. 2008-March 2009 for laparoscopic gastric banding to have one 16.9 months, the mean BMI was 34.9 ± 6.2 kg/m2. of two approaches. Conclusion: LSG seems to be effective as revisional procedure for Gr.A:The conventional way of LAGB without gastric plication failed LAGB/VBG, even if long term results needed to asses its Gr.B:LAGB with anterior gastric plication. We observed pattern of efficacy. The complications rate may be greater than LSG without weight loss, complication rate and need of adjustments in both primary procedures, although acceptable. groups. Results: we operated 50 patients in each group and followed up for one year. BMI was 42 and 43 kg/m2 respectively. Age and gender similar in both groups. Excess weight loss was 45% in Gr. A and 62% in B(p<0.005). Slippage rate was in 2 cases(4%) in A and Zero in B (p<0.05). Average number of adjustment 4 times in A and twice B. First adjustment after 4 weeks in A and 7 weeks in B. No band erosion. Conclusion: The early results of LAGB with gastric plication seem to be significantly superior to the conventional one to improve weight loss and decrease complication rate.

New Bariatric Concept: Laparoscopic Adjustable Banded Gastric Plication. Barium meal at 3th month PRESENTER: Chih-Kun Huang (E-Da Hospital)

Laparoscopic Greater Curvature Plication: Initial Results Of An Co-Authors: Chi-Hsien Lo1, Shabbir Asim1, Yaw-Sen Chen2, Po- Alternative Restrictive Bariatric Procedure Huang Lee2 PRESENTER: Almino Ramos (Gastro Obeso Center)

1. Bariatric & Metabolic International Surgery Center, E-Da Co-Authors: Manoel P. Galvao Neto1, Claudio C. Mottin3, Josemberg Hospital, Kaohsiung County, Taiwan. M. Campos2, Manoela Galvao1, Luis F. Evangelista2, Thales D. 2. General Surgery, E-Da Hospital, Kaohsiung County, Taiwan. Galvao1, Andrey Carlo1

Background: Laparoscopic adjustable gastric banding has been 1. Surgery, Gastro Obeso Center, Sao Paulo, Sao Paulo, Brazil. widely accepted to treat morbid obesity. However, the stagnant of 2. Surgery, Federal University of Pernambuco, Recife, Pernambuco, weight loss from poor compliance of patients made weight loss Brazil. slower and inconsistent. Here, we describe a novel technique for 3. Surgery, Pontific Catholic University of Rio Grande do Sul, Port Laparoscopic Adjustable Banded Gastric Plication( LABGP) to Alegre, Rio Grande do Sul, Brazil. augment and improve postoperative weight loss. Methods: After approval of ethics committee, LABGP was Background: Vertical Sleeve Gastrectomy (VSG) is a surgical implicated to morbidly obese patients after getting patient‟s consent. technique that involves resection of a significant portion of the Laparoscopic surgery with 5-ports technique was performed. Swedish stomach. This surgery is sometimes associated with gastric leaks, band was placed with pars flaccida method and then total vertical which can be difficult to treat. The present study reports findings gastric plication from fundus to lower antrum, 3 cm from pylorus was from Laparoscopic Greater Curvature Plication (LGCP), which is an performed with Ethibone suture and Endohernia staples. Pre- alternative bariatric procedure similar to VSG, but without the need operative data , intra and postoperative complications and length of for gastric resection hospital stay were recorded.Upper gastrointestinal series and GI QOL Methods: A prospective study was carried out, following LGCP in 65 questionnaire were done 3 months later postoperatively. And all morbidly obese patients (41 female/21 male) with a mean age of 33.5 patients were regularly followed up.Excess weight loss was analyzed. years (23 to 48) and mean BMI of 41.3 kg/m (35 to 46). Through a Results: Between May 2009 and February 2010, 20 morbid obese five-port approach, the stomach was reduced by dissecting the greater cases with a mean BMI of 40.47kg/m2(range 35-48) underwent omentum and short gastric vessels, as in VSG, the greater curvature LAGBP. Mean operation time was 81.9 min and patients were was then invaginated using multiple rows of non-absorbable suture discharged after 1.25 days in average. No surgical complication over a 32-Fr bougie to ensure a patent lumen happened. Mean %EWL at the 1st, 3rd, 6th and 9th month was Results: All procedures were completed laparoscopically. Mean 21.3%, 31.67%, 45.41% and 69.77% respectively. Till now, band operative time was 55 min (40 to 110 min) and mean hospital stay adjustment frequency was only 0.8 times/patient in this period. was 36 h (24 to 96). Patients returned to their regular activities an Conclusion: Laparoscopic Adjustable Banded Gastric Plication, a average of seven days (4 to 13) following surgery. No intra-operative combination of restrictive and reductive procedure, is safe, feasible complications occurred. All patients experienced excess weight loss and reproducible. It can offer excellent weight loss under a more (EWL) of at least 20% after 1 month. Mean EWL was 62.5% in 11 physiological concept. Long-term follow up for this procedure would patients after 18 months. There has been no record of weight regain be mandatory. in any patient to date Conclusion: LGCP is f a easible, safe and effective for at least 18 months when performed on morbidly obese patients. Longer follow- up and prospective comparative trials are needed

Gastric Plication:A New Option In Obesity Surgery.

PRESENTER: Juan Lopez-Corvala (Hospital Angeles Tijuana)

Co-Authors: Fernando Guzman-Cordero1, Francisco Ortega- Completed adjustable banded gastric plication Pallanez1

1. Hospital Angeles Tijuana, San Ysidro , CA, United States.

Background: There are reports of a new technique which simulates the sleeve gastrectomy without stomach removal. In 2009, we initiated a protocol with this procedure which resulted in a similar weight loss to that of the sleeve gastrectomy. Methods: Under general anesthesia, with the patient in french position, the first trocar is placed 10mm to the left of the umbilicus and 10cm under the rib cage. The rest are placed under direct vision. We begin the devascularization of the greater curvature at 5cm of the pylorus with the harmonic scalpel (Ethicon) up to the His Angle. The stomach is previously calibrated with a 32 fr bougie. We begin suturing at the His Angle between the posterior and anterior gastric wall with separate stitches of prolene 00 until we reach 5 cm above the pylorus. A continuous suture is then performed imbricating the previous suture with the same material following the same references. We then verify hemostasis, checking the site of entry of the trocars and then removed under direct vision. Extraction of pneumoperitoneum is done the skin is closed with monocryl 000 Results: Hospital stay was 48 hrs in which the patient had no complications. The post-op upper GI was normal. In 3 months, the patient lost 30kg, presented no reflux and his hypertension is under control without medication. Conclusion: This new procedure is an excellent option for the obese patient, particularly for high risk patients. After 6 months follow-up on our grastric plication patients, we have seen the same results in excess weight loss as in the sleeve gastrectomy but with a lower complication rate and less costly. However, more studies are needed to insure its place in obesity surgery even though the initial results seem promising.

IHO-001 A Protocol For Investigation Of Gastric Band System Leakage

PRESENTER: Narelle Story (Ausralian Bariatric Nursing) Co-authors: Narelle M. Story1

1. Sydney Institute of Obesity Surgery, Ashfield, NSW, Australia. 2. Ausralian Bariatric Nursing, Sydney, NSW, Australia.

Background: Some long term gastric band patients are observed to report a re-emergence of a loss in satiety and satiation plus a tolerance to all foods and textures. This may be an entirely subjective experience. Alternatively, it may represent a leak of fluid from the band system. A protocol for the assessment of tubing or port leakage is therefore recommended. Methods: Given that some bands are either 10mls or 14 mls in size, it is appropriate to evaluate the amount of residual fluid in the band using a 20 ml syringe. Once the volume is less than would be expected, a leak is suspected. The band can then be assessed either radiologically or clinically. The port is accessed in the radiology suite and up to ten mls of contrast instilled. The band is then surveyed for leaks. If no leaks are A port with needling injury to sideport and retrograde flow apparent, scanning is resumed after half an hour. If no leak is under the scar capsule around the port evident, then the contrast amount is reviewed and an appropriate adjustment made. The patient is then rechecked after one week. If fluid has been lost by the return visit,a leak is confirmed and the system should be replaced surgically. Results: Our observations of band system leakage have found that waiting thirty minutes after instilling contrast can be helpful in elucidating the region of leakage. X-rays of a frayed tube with contrast enhancement around the small intestine, a port backplate leak and a port that has been needled in the side-port are depicted. All were diagnosed using the described protocol. Conclusion: Establishing if a band is leaking can be a difficult situation. Devising a protocol is important for establishing and managing this band problem. The x-ray depiction of some common occurrences and the technique in achieving them may be of value to health care professionals conducting band adjustments in an after care clinic.

Intestinal shadowing from contrast leak from frayed tubing

IHO-002 South African Bariatric Surgery Outcome Data: No AST Experience Of 261 Patients 25±0.6 25±1.1ns 20±0.7* Treatmen (U/L) t PRESENTER: Gary Fetter (Center of Excellence) No GGT 40±3.3 27±2.2*** 22±3.0*** Treatmen (U/L) Co-authors: Jenny H. Pieters1, Annelie Maree1, Maria-Terésa t Van der Merwe1 No Drug 0.2±0.04** 3.8±1.0 0 Treatmen Classes * t 1. Metabolic Medicine and Surgery, Center of Excellence, Johannesburg, Gauteng, South Africa. Data in mean ± SEM Students t-test Background: To assess clinical, biochemical and surgical *p<0.05* **p<0.01 ***P<0.001 outcome data over 3-12 months after intervention. Methods: 261 patients undergoing surgery 2007 - 2009. Lap- GBP’s: 86% of patients. Analyzed F-glucose, lipids, liver functions, CRP. Pharmacotherapy recorded. Gastroscopies: N=151 at 3 months. IHO-003 Quality Of Life (QOL), Excess Weight Loss Results: G-scope 3 months: stomal ulceration 4.6%; Surgical (EWL) And Resolution Of Comorbidity Status At Four morbidity: Major < 3mo; 7.3%, Major > 3mo; 3.0%, total Years After LSG :Are They Related? 10.3%. Minor < 3mo; 2.6%; Minor > 3mo; 2.3%, total 4.9%. Surgical mortality: 0%; Medical mortality: 0.7%; Serious medical morbidity (12mo), 4.6%. Conclusion: 1. Metabolic Syndrome shows significant PRESENTER: Jayashree Todkar (Ruby Hall Clinic) improvement 3-12 mo post surgery. 2. Morbidity, mortality is low in high volume bariatric centre. 3. Pharmacotherapy Co-authors: Shashank S. Shah1, Poonam S. Shah1, Arundhati decreased from 3.8 drug classes to 0. M. Khadilkar1

Preoperativ 1. Surgery, Ruby Hall Clinic, Pune, Maharashtra, India. Postoperative e 12 mo N=251 3 mo N 161 N=99 Background: Measuring the mechanisms of outcome is critical for determining the success after bariatric surgery.We studied Weight 112±2.1** 126±2.3 100±2.6*** %EWL ,co morbid status resolution and QOL as the (kg) * parameters after LSG at the end of four years. 136±1.6** Methods: Prospective study of the retrospectively collected BP (S) 147± 1.2 140±3.8*** * data for consecutive 23 patients operated for LSG between 2004 and 2005 is done.All patients were operated by a single BP (D) 87±0.8 80±1.1*** 85±2.3** surgical team and managed by a single multidisciplinary team. F- No M:F(8:15) .The %EWL,comorbid disease status and QOL is Glucose 6.0±0.2 5.1±0.1*** 5.3±0.4* Treatmen compared preop and postop. Student’s t test was performed to (mmol/L t define the correlation between these parameters. ) Results::: % EWL at 24 months was 74.578%. 16 / 23 Pts F-T-Chol No demonstrated improvement in all co-morbidities and the rest (mmol/L 5.1±0.1 4.4±0.1*** 4.9±0.4 ns Treatmen (7 / 23 ) showed at least one major co-morbidity improvement. ) t QOL improved in all ,but not equally in all parameters of the questionnaire. BAROS total outcome score was good in 4/23 , F-LDL No very good 4/23 , and excellent 15/23.EWL and comorbid (mmol/L 3.2±0.1 2.8±0.1*** 2.8±0.1** Treatmen status resolution strongly correlate with eachother and show ) t improvement over time. QOL and EWL showed weak F-HDL No correlation with eachother. (mmol/L 1.2±0.1 1.1±0.02ns 1.5±0.1* Treatmen Conclusion: LSG is a weight loss surgery and results in ) t resolution of comorbidities.However it does not change a person’s QOL proportionately.Psychological and social F-TG No ns systems are required to increase this facet of outcome if we (mmol/L 2.1±0.2 1.9±0.2 1.8±0.3* Treatmen have to advance overall success and well being of our patients. ) t No ALT 33±1.3 30±1.5 ns 25±1.9* Treatmen (U/L) t

IHO-004 Interdisciplinary Quality Assurance Instrument in Surgical and Conservative Intervention 1. Department of Nutrition and Dietetics, Chelsea and Westminster Hospital, London, United Kingdom.

2. Department of Surgery, Chelsea and Westminster Hospital, PRESENTER: Karl Miller (Hallein Clinic) London, United Kingdom.

Co-authors: Daniel Weghuber2, Elisabeth Ardelt-Gattinger3, 3 4 Background: This study aimed to investigate the preoperative M. Meindl , Susanne Ring-Dimitriou predictors of unrealistic weight loss expectations in patients awaiting bariatric surgery in an urban bariatric surgery centre 1. Surgical Department, Hallein Clinic, Hallein, Austria. in the United Kingdom. 2. Pediatrics, Paracelsus Private Medical School Salzburg, Methods: We completed a retrospective analysis of patient Salzburg, Austria. record cards. Internationally accepted expected weight loss for 3. Department of Psychology, University of Salzburg, each procedure was compared to patient’s expectations for Salzburg, Austria. weight loss following surgery. Factors including age, gender, 4. Department of Sport Science & Kinesiology, University of ethnicity, weight and BMI at assessment, previous dieting Salzburg 6 , Salzburg, Austria. attempts, previous successful weight loss, sweet eating, binge eating, and surgery type were considered in our analysis.

Results: 731 dietetic assessments were completed between Background: Interdisciplinary state-of-the-art interventions to October 2002 and October 2009. The majority were female (f treat obesity demand equally interdisciplinary outcome 71%, m 29%). Overall, 71% of patients had unrealistic weight assessment. The BAROS (Oria & Moorehead, 1998) is limited loss expectations. Multiple logistic regression analysis to adults and medical and quality of life outcome parameters. revealed that there was no significant difference for age, race, It was the aim of the current project to establish an BMI, comfort eating, self reported binge eating, chosen interdisciplinary instrument for quality assurance (BAROS- surgical procedure, number of previous diet attempts or CA) to reliably assess conservative and bariatric obesity successful previous weight loss. The only factor of treatment. significance for unrealistic weight loss expectation was female Methods: Medically relevant parameters of obesity gender (p = 0.003). Univariate analysis revealed a trend comorbidities (―metabolic syndrome‖) were selected. The towards significant difference for self-reported binge eaters literature was searched for additional potential and for patients awaiting gastric bypass procedures. interdisciplinary aetiological variables as measured with the Conclusion: Our study supports the literature that the majority test kit AD-EVA with existing empiric evidence or at least of patients overestimate the amount of weight they are likely high plausibility. The variables were tested in a cross-sectional to lose from surgery. Females are more likely than males to study of a representative sample (N=4000, age 18 - 65) to overestimate the weight loss they are likely to obtain from evaluate whether they allowed to discriminate between surgery. There is a slight trend for patients awaiting gastric different BMI categories. Moreover, the predictive value of bypass to overestimate weight loss compared to those awaiting the variables was tested in a longitudinal study (N=150, age 25 gastric banding. Pre-operative education of patients continues - 62). Thereby identified relevant aetiological variables were to be an essential area, including a focus on realistic categorised and included. expectations after surgery. Results: The BAROS allows to identify and quantify significant changes of interdisciplinary variables associated with obesity for groups and individuals (tables of critical differences) as well. The degree of success or failure of an intervention can be quantified for each of the disciplines and is IHO-006 A Prospective Comparison Of Three also given as a total value on a scale of 1-7. Laparoscopic Bariatric Procedures: To Define The Conclusion: The BAROS is the first interdisciplinary quality Indication Of Each Operation. assurance instrument for pre/post intervention evaluation of obese individuals as well as groups. It can be applied for intervention studies but also provides the clinician with a PRESENTER: Francesco Stipa (San Giovanni Hospital) quick but differentiated overview in daily practice. Co-authors: Valentina Giaccaglia1, Antonio Burza1, Ettore 1 Santini

IHO-005 Predictors Of Unrealistic Weight Loss 1. Surgery, San Giovanni Hospital, Rome, Italy. Expectations Of Patients Awaiting Bariatric Surgery Background: The aim of this study was to compare the effect PRESENTER: Kelli Edmiston (Chelsea and Westminster on comorbidities and failure rates of three common bariatric Hospital) surgical procedures performed laparoscopically: adjustable gastric banding (AGB), sleeve gastrectomy (SG) and gastric bypass (GBP), in order to define the proper indication of each Co-authors: Evangelos Efthimiou2, Paris Tekkis2, Caroline S. 1 2 2 operation. Shannon , Fionnuala Davison , Gianluca Bonanomi Methods: Between 2006 and 2010 we operated on 90 morbidly obese patients performing AGB (n=30), SG (n=20) pancreatic enzyme preparations was 7.5 weeks (range 5-12). and GBP (n=40). The selection of the operation was based on Median serum albumin rose from 23.5 g/l to 37.5g/l during patient/surgeon discussion. The analyses included the this period, with bowel frequency decreasing to 2-3 motions following variables: age, sex, body mass index (BMI), dietary per day. At follow up all patients maintained serum albumin history, the presence of eating disorder and comorbidities levels within the normal range, with a median protein intake of (depression, diabetes, gastroesophageal reflux, hypertension, 100g per day. obstructive sleep apnea, hyperlipidemia, joint disease). The Conclusion: The provision of 100g protein per day, pancreatic percentage of estimated weight loss (EWL) was assessed. The enzyme supplementation and loperamide can restore serum mean follow up was 31 months. albumin levels to within normal limits. Once serum albumin Results: In the three groups the mean preoperative and levels had been restored to normality this could be maintained postoperative BMI and the %EWL were the following: AGB by a protein intake of 100g per day. This regimen has now group (mean age=41) 42.4, 35.4, 36%, SG group (mean become standard practice in our units. age=33) 44.6, 32.8, 57.5 %, GBP group (mean age=43) 45.3, 34.2, 51.5%. Women responded better than men with %EWL of 57.5% vs 42.2%, respectively. Failure rates were 23% for AGP, 0% for SG and 5% for GBP. Resolution of comorbidities were 100% for AGP, 75% for SG and 85% for IHO-008 Should Additional B12 be Prescribed Following a GBP. Laparoscopic Roux-en-Y Gastric Bypass? Conclusion: In our experience AGB is indicated in obese patients who prefer a reversible operation, preferably young women without eating disorders. SG is indicated in patients PRESENTER: Jayne Brocklehurst (Gravitas Centre for without gostroesophageal reflux disease, fertile women and Bariatric Surgery) men of all ages with comorbidities. GBP is indicated in patients with eating disorders and comorbidities. Co-authors: Conor Magee1, Simon Weaver1, Robert Macadam1, Shafiq Javed1, David Kerrigan1 1. Gravitas Centre for Bariatric Surgery, Liverpool, United Kingdom. IHO-007 Effective Management of Protein Malnutrition Following Duodenal Switch Surgery Background: The aim of this study was to establish the prevalence of vitamin B12 deficiency following Laparoscopic

Roux-en-Y Gastric Bypass (LRYGB), and to determine if PRESENTER: Jayne Brocklehurst (Gravitas Centre for additional B12 supplements should be given post operatively Bariatric Surgery) as routine practice. Methods: 163 patients (132 female and 31 male) who had at Co-authors: Conor Magee1, Simon Weaver1, Robert least two year follow up were selected from a prospective Macadam1, Shafiq Javed1, David Kerrigan1 bariatric database. All patients started a multivitamin and mineral preparation post operatively which contained 3ug

Cyanocobalamin. Blood tests were analysed at 3, 6, 9,12, 18 1. Gravitas Centre for Bariatric Surgery, Liverpool, United and 24 months post operatively to determine the prevalence of Kingdom. vitamin B12 deficiency. Results: Median age was 42 years (range19-67), and median Background: Protein malnutrition following a duodenal switch pre operative BMI was 48.4Kgm2 (range 32-68). Median % procedure is a relatively infrequent occurrence, however when excess weight loss was 75% and 81% at 12 and 24 months hypoalbuminemia occurs, periods of enteral or parenteral respectively. 27% of patients developed vitamin B12 supplementation can be required. We present a series of deficiency. Median time of presentation was 10 months (range patients with low serum albumin levels who were successfully 4-24 months). Deficiency was treated with Hydroxocobalamin managed with pancreatic enzyme preparations, anti-motility 1mg IM every 3 months. All B12 levels were back within drugs, and a high protein diet. normal range on repeat blood tests 3 months later, and Methods: Eight patients presented to the team with significant remained within normal range on subsequent blood tests. hypoalbuminemia (< 30 g/l: reference range 36- 50 g/l) Conclusion: The results of this study show 27% of patients following a duodenal switch procedure. Median time of develop vitamin B12 deficiency following a LRYGB. In our presentation was 20 months after surgery. Median protein units we feel this does not warrant routine parenteral vitamin intakes were calculated to be 85 g protein per day. Diarrhoea B12 supplementation in addition to the standard multivitamin was present in four of these patients. Dietary advice was given and mineral supplement. Instead close monitoring and 1mg IM to provide 100g protein per day. Symptomatic control of of Hydroxocobalamin every 3 months is sufficient to correct diarrhoea was achieved through the use of loperamide. To and maintain B12 levels within normal ranges. improve the absorption of protein, pancreatic enzyme supplements (Creon, Solvay, Brussels) were introduced in all patients, and continued until normalisation of serum albumin levels had been achieved. IHO-009 Probiotics, Prebiotics, Gut Microbiota and Results: The median length of time for which patients required Obesity: Can Manipulation of the Gut Microbiota Accentuate Gastric Bypass Success? A review. obese patients are hypometabolic, which makes it more difficult for them to lose weight and to maintain it in the long PRESENTER: Margaret Furtado (Johns Hopkins term. Bayview Medical Center) Methods: Twenty-eight patients—twenty-seven female and one male—underwent an indirect calorimetry (Fitmate/Cosmed®) and repeated the exam 12 months after 1 1 Co-authors: Silvia L. Faria , Orlando P. Faria the operation. The calorimetry was carried out in a 12 hour 1. Gastrocirurgia de Brasília, Brasília, Distrito Federal, Brazil. fast. Weight and height were measured. This study was 2. Clinical Nutrition, Johns Hopkins Bayview Medical Center, approved by the ethics committee from Santa Luzia Hospital, Baltimore, MD, United States. in the Federal District. Results: The patients showed an average energy expenditure

of 1,702 ± 58 kcal/day in the preoperative period. In the Background: Recent researches suggest that probiotics, postoperative period, the average basal metabolic rate was prebiotics, and/or the combination of the two may alter gut 1,445 ± 47 kcal/day and there was a significant difference microbiota, and may play a role in weight loss, possibly between the means. A positive correlation was found between altering obesity mechanisms. the basal metabolic rate in the postoperative period and weight Methods: A literature review was performed using the and BMI. PubMed and MEDLINE databases for articles published on Conclusion: The basal metabolic rate is accounted for over gut microbiota and obesity since 2004. 70% of total energy expenditure. If there is a loss of lean Results: We selected 8 articles from 2004 to 2009. mass, there can be a steeper decrease of energy expenditure Investigators have discovered that individuals with obesity and, consequently, a difficulty in losing and maintaining appear to have significantly higher amounts of the microbiota weight. Nutritional follow-up allows a better adjustment class of Firmicutes and lesser amounts of Bacteroidetes. After between energy expenditure and calorie consumption, thus gastric bypass surgery, researchers have determined that helping in weight loss and maintenance in these patients. Firmicutes significantly decreased, with a significant increase of another class of bacteria, Bacteroidetes. Prebiotics help to feed healthy gut microbiota, and may enhance probiotic efficacy. Utilizing nutritional genomics and applying IHO-011 The Effect Of Weight Loss On Musculoskeletal randomized, double-blind technique, subjects were divided Pain In The Morbidly Obese into two groups s/p RYGBP surgery, one with probiotics, and the other placebo. The hypothesis is that genomic research will elucidate that those individuals in the probiotics group PRESENTER: Mervyn Deitel (Editor-in-Chief Emeritus, will display significant changes in gut microbiota, namely a Obesity Surgery) significant increase in Bacteroidetes vs. Firmicutes, and perhaps a significant increase in Gammaproteobacteria. Co-authors: Kevin Deitel2, Wayne Deitel3 Conclusion: The literature shows that prebiotics can play an important role among bariatric population. The diet of all subjects can be evaluated and weight loss can be compared 1. Editor-in-Chief Emeritus, Obesity Surgery, Toronto, ON, among all subjects within the multi-country study to assess Canada. whether the diet, regardless of probiotic assignment, may play 2. Orthopedic Spine Surgery, Scripps Encinitas Hospital, a role in post-op RYGBP surgery. Encinitas, CA, United States. 3. Diagnostic Imaging, St. Michaels Hospital University of Toronto, Toronto, ON, Canada.

Background: Obesity causes increased mechanical load on the IHO-010 ssessment Of Energy Expenditure In Pre- And weight-bearing joints.

Postoperative Periods In Rygb Patients. Methods: 104 morbidly obese patients (mean preop weight 125 kg; age 15-58, mean 33.4 years) were studied PRESENTER: Silvia Faria (Gastrocirurgia de Brasília) prospectively to determine incidence of chronic musculoskeletal pain. All patients completed a standardized questionnaire, orthopedic examination, and x-rays of Co-authors: Orlando P. Faria1, Rafael Galvão1, Margaret 2 symptomatic joints before and after bariatric surgery. Furtado Results: 88% of the morbidly obese patients suffered from pain in one or more weight-bearing joints most days. This pain 1. Gastrocirurgia de Brasília, Brasília, Distrito Federal, Brazil. was frequently an incidental symptom rather than the primary 2. Clinical Nutrition, Johns Hopkins Bayview Medical Center, reason for seeking bariatric surgery. The sites of chronic pain Baltimore, MD, United States. before and after bariatric surgery were: Low back 62% vs 11%, Hips 11% vs 2%, Knees 57% vs 14%, Ankles 34% vs Background: Indirect calorimetry is a reliable method of 2%, Feet 21% vs 1% (mean 22.5 mons postop, mean wt loss assessing energy expenditure. In obese patients it becomes 44 kg – least 16 kg. 2 patients who had lost >45 kg with even more important, since knowing calorie consumption resolution of back pain, later regained the excess weight helps in prescribing a more effective diet orientation. Many accompanied by return of the back pain. Conclusion: Loss of excess body weight significantly differences ceased to be significant after the 12th month (and decreased the pain in these joints, with increase in mobility after the 6th month in lean mass). Regarding risk factors, in a and activities of daily living. sub-sample of 122 patients, Sleeve caused a higher decrease in blood pressure (maxima and minima) in months 9, 12 and 15 (although the differences were not statistically important). In a

sub-sample of 106 patients with high glucose (>100) sleeve resulted in a higher percentage decrease in glucose in the first IHO-012 Seven Years Sequential Study With Lap Band 12 months (although not statistically significant). With 97.8% Follow-Up Conclusion: Sleeve performed better than GB with respect to weight, fat mass, blood pressure and glucose decline PRESENTER: Antonio Silva (Obesity Surgery, Hospital (especially in the first 12 months). However, lean mass loss do Carmo, Porto, Portugal) was lower in GB. Background: A sequential study of a group of patients followed at least of a period of 7 years to evaluate gastric banding on the treatment of severe obesity Methods: All the patients were submitted a laparoscopic IHO-014 Increased Weight Loss with Roux-en-Y Gastric gastric banding using Lapband before the end of the year Bypass Among Sugar Cravers and Excessive Consumers 2002. Surgery was done allways by laparoscopy, using the pars flacida technique. Patients had an intensive follow-up. PRESENTER: Kerry Ferguson, PhD 180 severely obese patients with an average BMI of 46.6 at the outset were followed with a high rate (97.8%) for seven years, 94% of the patients retained the gastric banding. Co-authors: Keith Kim1, Cynthia K. Buffington1 Results: 176 patients completed the 7 year follow-up study.

Average % EBMI loss was at 3 years was 67% and remained 1. Metabolic Medicine and Surgery Institute, Florida Hospital stable through year 7. Comorbidities present in 70% of the Celebration Health, Celebration, FL, United States. patients were resolved in 60%. 94% of bands continue in 2. Kerry B Ferguson, Ph.D., Celebration, FL, United States. place, 8 patients were converted into gastric bypass or sleeve gastrectomy. No mortality. Severe morbility ocurred in 15% of the patients. Background: Sugar craving and excessive consumption are Conclusion: Laparoscopic adjustable gastric banding is believed to contribute to weight gain and/or regain. In this suitable for treating severly obese patients with good results study, we examine the association between sugar and low morbidity on long term craving/consumption and surgical weight loss success, along with measures of psychological status. Methods: Sugar craving and excessive consumption were assessed by a survey provided to bariatric surgical candidates IO-013 Weight Loss, Fat Mass Loss And Risk Factors In prior to and following laparoscopic Roux-en-Y gastric bypass Gastric Banding And Sleeve Methods (LRYGBP) or the adjustable gastric band (LAGB). Body weight and BMI were examined prior to surgery and, again, an average of 22 months postoperatively. Psychological status PRESENTER: Diane Lazaridis (Neo Athineon Hospital) was assessed with the Millon Behavioral Medicine Diagnostic (MBMD) and Minnesota Multiphasic Personality Inventory Co-authors: Nikolaos Koutsogoulas1, Youla Boura1, Odysseas (MMPI-2). Boudouris1 Results: The data show that 44% of the bariatric candidates consider themselves sugar cravers and excessive sugar

consumers. Statistical analyses indicate no significant 1. IMOP Unit of Bariatric Surgery, Neo Athineon Hospital, differences between the sugar or non-sugar cravers/consumers Athens, Greece. with regard to preoperative BMI, body weight or age. Sugar

cravers/consumers have significantly (p<0.05) higher scores Background: Gastric Banding (GB) and Sleeve are common on the MBMD Introversive and Medication Abuse scales, therapeutic methods for morbid obesity. Our purpose is to indicating a tendency to be more emotionally subdued and compare these methods in terms of weight loss, fat mass loss medically passive and to have higher risk for misuse of and their effect upon risk factors (blood pressure and glucose). medications. Total % change in BMI with surgery is Methods: Patients undertaken surgery between June 2006 and significantly greater for the sugar vs. the non-sugar February 2010 were included. The study refers to 1.5 years cravers/consumers, i.e. 42% vs. 33%. The surgery-induced follow-up. Factorial Analysis of Variance (ANOVA) and decline in BMI with the LRYGBP, but not the LAGB, is ANOVA for repeated measurements were utilized to perform significantly more for the sugar vs. non-sugar statistical tests. carvers/consumers. Results: 170 patients, fully documented, were included (mean Conclusion: Individuals who crave sugar and are excessive age: 39.6 ±10.9; women: 122/170; GB: 127 vs. Sleeve: 43). sugar consumers lose more weight with bariatric surgery, Sleeve led to higher overall percentage decline in weight particularly the LRYGBP, than do their non-sugar craving (p<0.001), fat mass (p=0.002), lean mass (p=0.035), BMI (p=0.002) and EFM (excess fat mass) (p<0.001). However, the counterparts.

IHO-015 Eating Habit Profiles of Obese Men and Women Seeking Laparoscopic Banding Surgery

PRESENTER: Susan Franks (Family Medicine, University of North Texas Health Science Center, Fort Worth, TX, United States)

Background: The purpose of this study was to characterize the eating habits of obese men and women seeking laparoscopic banding surgery (LBS) that may place them at risk for dietary non-compliance. Methods: Adults (105 women, 40 men) with an average BMI of 52.2 (sd=7.56) completed the Eating Habits Survey (EHS) of the Weight and Lifestyle Inventory as part of a pre-surgical psychological evaluation for LBS. The EHS is comprised of 24 items assessing eating behaviors to which respondents attribute their increased weight on a scale of 1(not at all) to 5 (greatest amount). The EHS items form 5 factors: eating in response to negative affect (NA), eating in response to positive affect and social cues (PS), general overeating and impaired appetite regulation (OI), overeating at early meals (EM), and snacking (SN). Demographic relationships and differences among the factors were analyzed using Pearson correlation, t-test, and analysis of variance. Results: BMI was equivalent for gender, age, marital status, and ethnicity. In comparison to other EHS factors, the highest percent of men (32.5%) and women (37.1%) rated SN as contributing the largest amount to their weight problems, followed by OI for men and NA for women. Women rated NA higher than men (F=7.969, p=.005), with 32.4% of women and 7.5% of men ranking it as the largest contributor. All other comparisons were non-significant. Conclusion: Men and women seeking LBS differ in the degree to which various self-reported eating habits are perceived as contributing to their weight problems. Snacking is the most problematic regardless of gender, while women are more vulnerable than men to the impact of negative emotions on caloric intake. Snacking and negative emotional eating may represent specific behavioral risks to long-term dietary compliance and should be targeted for improved post-surgical outcomes.

V-001 Totally Robotic Revision Of A Gastrogastric Fistula 1. Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Brussels, Belgium.

PRESENTER: Keith Kim (Florida Hospital Celebration Health) Background: With the advent of single incision laparoscopic Co-authors: Keith Kim1, Arundathi Rao1, Eduardo Parra-Davila1, surgery, different procedures have been reported to be feasible and Cynthia K. Buffington1 safe through this approach. The authors report a removal of laparoscopic adjustable gastric banding (LAGB) through a single

incision using new curved and reusable instruments. 1. Metabolic Medicine and Surgery Institute, Florida Hospital Methods: A 31 year-old man consulted for intolerance after LAGB, Celebration Health, Celebration, FL, United States. placed 5 years before for morbid obesity (BMI: 40 kg/m2). A total weight loss of 25 kg was achieved during follow-up. Preoperative Background: Revisional surgery for gastrogastric fistula (GGF) is weight and BMI were 114 kg, and 33 kg/m2 respectively. After complex and associated with a higher risk for complications than multidisciplinary counseling, a single access laparoscopic removal primary Roux-en-Y gastric bypass (RYGBP) procedures. Robotics was proposed to the patient. An incision in the left upper quadrant with its superior visualization and maneuverability of instruments was performed. The subcutaneous port was removed and the tubing may reduce surgical risks of revisional surgery. In this video was cut. The peritoneal cavity was entered thanks to the Hasson presentation, we illustrate the safety and feasibility of totally robotic technique. A non disposable 11-mm trocar was inserted in the cavity surgery in revision of a GGF. for a 10-mm 30° angled, non flexible, and standard length scope. Methods: A 42-year old female who was 4 years post-laparoscopic New curved and reusable instruments (Karl Storz-Endoskope) as RYGBP presented with chronic pain, acid reflux and weight regain. grasping forceps I, coagulating hook, and scissors were used. The An upper GI showed a large GGF with preferential filling of the band was freed from adhesions with the left hepatic lobe, and remnant stomach, and upper endoscopy showed an anastomotic opened cutting its surface. After its removal through the single stricture with ulcerations. The GGF involved most of the lateral wall access, the latter was closed tying the purse string sutures. of the gastric pouch. Totally robotic revision was performed in a Results: Total operative time was 58 minutes, and laparoscopy took stepwise manner: 1) isolation of the gastrojejunal anastomosis, 2) 37 minutes. Blood loss was insignificant. Final incision length was subtotal gastrectomy of the remnant stomach to include division of less than 30 mm. Postoperative course was uneventful, and the fistula, 3) closure of the gastric pouch side of the fistula, and 4) postoperative pain kept minimal. The patient was discharged on the reconstruction of the gastrojejunostomy. 1st postoperative day. Results: The totally robotic procedure involved no surgery-related Conclusion: LAGB removal is feasible and safe to be performed by complications. The patient was started on clear liquids on single access. Curved and reusable instruments help surgeons to postoperative Day 1 and was discharged home on full liquids on perform this procedure maintaining ergonomy and working postoperative Day 2. The patient required no readmissions for triangulation inside the abdomen as well as outside, similar to dehydration, vomiting or any other surgery-related adversity and her classic laparoscopy. body weight declined by nearly 10%. Since this procedure, we have performed 12 other totally robotic revisional surgeries, with 0% leaks, no re-operations and no blood transfusions. Conclusion: Totally robotic revisional surgery is feasible and the V-004 Laparoscopic Conversion Of Standard Roux-En-Y increased visualization, precision, and maneuverability of the Gastric Bypass To Distal Gastric Bypass procedure may reduce surgical risks and complications. PRESENTER: Giovanni Dapri (European School of

Laparoscopic Surgery)

V-002 Laparoscopic Reversal Of Roux En Y Gastric Bypass Co-authors: Guy-Bernard Cadière1, Jacques Himpens1 PRESENTER: Muhammad Jawad (Bariatric and Laparoscopy Center of Ocala) 1. Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Brussels, Belgium. Background: Since Jan.1999-Dec.2009,2669 R-Y gastric bypasses were performed by the the author;2570 laparoscopic and 99 open. Background: We report the laparoscopic strategy to convert a Four patients required reversal due to recurrent anastamotic ulcer. standard Roux-en-Y gastric bypass (RYGB) into a distal RYGB Methods: Video presentation illustrates the method of laparoscopic (DRYGB) in a patient presenting weight regain. reversal of R-Y gastric bypass Methods: In November 2004, a 37 years old female underwent to Results: No further recurrence of the ulcers in any of the four laparoscopic RYGB for morbid obesity (weight 118 kg, BMI 50.4 patients after reversal,although they all regained their weight. kg/m2). After one year she presented a weight loss of 42 kg (BMI Conclusion: Laparoscopic reversal of R-Y gastric bypass is feasable 33 kg/m2). The weight remained stable for the following 3 years. At and successful for the treatment of recurrent anastamotic ulcer. 4th year she started regaining weight, and in April 2009 the weight was 89 kg (BMI 38 kg/m2). Because of the psychological and

alimentary decompensation induced by the weight regain, the V-003 Laparoscopic Gastric Banding Removal Through A patient was re-evaluated by a multidisciplinary team, and a Single Access Using New Curved And Reusable Instruments conversion to DRYGB was proposed. Laparoscopy was performed using four trocars. After complete adhesiolysis, the gastrojejunostomy was identified and the alimentary limb was PRESENTER: Giovanni Dapri (European School of measured and appeared to be 110 cm. At the jejunojejunostomy, in Laparoscopic Surgery) order to identify peroperatively each limb, 3 differently colored Co-authors: Wajih Riakos1, Daniela Baldoli1, Lorenzo Casali1, stitches marked the alimentary, the biliopancreatic and the common Guy-Bernard Cadière1, Jacques Himpens1 limbs. The alimentary limb proximal to the jejunojejunostomy was sectioned by a firing of linear stapler. The small bowel coming from the ileocaecal valve (new common limb) was measured so as to reach a total of 300 cm, including the previous alimentary limb. At Co-author: Janey S. Pratt2 that level a new jejunojejunostomy, between the alimentary and the new common loops, was performed by linear mechanical technique. 1. Surgery, Naval Medical Center San Diego, San Diego, CA, The new mesenteric defect was closed by a non absorbable purse- United States. string suture. 2. Surgery, Massachusetts General Hospital, Boston, MA, United Results: Operative time was 135 minutes. Patient was discharged on States. 5th postoperative day. At 5 months the patient is well, with no evidence of liver disease or protein malnutrition, the weight is 75 kg, and the BMI is 32 kg/m2. Background: Laparoscopic Roux-en-Y gastric bypass (LGBP) Conclusion: Conversion of RYGB to DRYGB for weight regain can remains the “gold standard” weight loss procedure and most successfully be performed by laparoscopy with satisfactory early bariatric surgeons use a set operative technique. We present an results. alternative approach for Roux limb construction when access to the infra-mesocolic abdomen is challenging. Methods: The patient is a 46 year-old super-super obese woman with a BMI of 67 kg/m2 and PMHx of HTN, HLP, GERD and V-005 Laparoscopic Conversion Of Roux-En-Y Gastric Bypass OSA. Her PSHx is significant for CCY and TAH/BSO. She was To Sleeve Gastrectomy As First Step Of Duodenal Switch deemed a suitable candidate for weight loss surgery and consent was obtained for a LGBP. Initial intra-abdominal inspection revealed PRESENTER: Giovanni Dapri (European School of limited working space due to profound visceral obesity, a massive Laparoscopic Surgery) omentum and dense adhesions in the lower abdomen. Due to these limitations, avoiding the infra-mesocolic abdomen by using an anterior approach to the ligament of Treitz was optimal. This video Co-authors: Guy-Bernard Cadière1, Jacques Himpens1 highlights the steps of this useful technique to create a retrocolic roux limb and tension-free gastro-jejunostomy. 1. Department of Gastrointestinal Surgery, European School of Results: Successful completion of a LGBP in a super-super obese Laparoscopic Surgery, Brussels, Belgium. patient with limited abdominal domain and significant adhesive disease from prior abdominal surgery. The operation was performed in 210 minutes with 50 cc of estimated blood loss. Her recovery was Background: Laparoscopic Roux-en-Y gastric bypass (RYGB) is uneventful and she was discharged home on post-operatively day 2. one of the most common bariatric procedures performed, Five and a half months later she was doing well and had 35% of laparoscopic sleeve gastrectomy (SG) is rapidly challenging EBWL. popularity. We report the laparoscopic conversion of RYGB to SG Conclusion: The anterior approach to the ligament of Treitz for as first step of duodenal switch (DS), for weight loss issues due to Roux limb construction during LGBP is a useful alternative new sweet-eating behaviour. technique in the armamentarium of the laparoscopic bariatric Methods: The procedure involved the dismanteling of both surgeon. gastrojejunostomy and jejunojejunostomy, with the restoration of the small bowel continuity, and performing the SG before the restoration of the gastric continuity between the gastric pouch and the gastric remnant. Between August 2007 and November 2009, 4 V-007 Laparoscopic Conversion Of V.B.G To R-Y Gastric patients benefited from laparoscopic conversion of RYGB to SG. Bypass Mean weight, BMI at RYGB was 118.5 kg (90-152), and 43.2 kg/m2 (35-52) respectively. Two patients suffered of obesity related PRESENTER: Muhammad Jawad (Bariatric and Laparoscopy co-morbidities. Mean time between RYGB and conversion to SG Center of Ocala) was 36.7 months (17-55). At conversion, the mean weight, BMI, %EWL was 101.7 kg (80-130), 37.3 kg/m2 (31-44), and 27.5% (15.5-41.8) respectively. Both patients had resolution of obesity related co-morbidities. Background: From Dec.2003 to Dec. 2009 12 patients were Results: Mean operative time was 233.7 min (195-300). There were converted from V.B.G to R-Y gastric bypass by the author (9 open no conversions to open surgery and no mortality. Gastric continuity and 3 laparoscopic).Reason for conversion; was fashioned as manual anastomosis, and small bowel continuity Persistant vomiting solid food due to outlet obstruction as linear mechanical. One patient developed a fistula at the site of Severe reflux with aspiration pneumonia the gastrogastrostomy. Mean hospital stay was 20.2 days (5-40). Disruption of the staple line After a mean follow-up of 11 months (3-30), the mean weight, BMI, Weight gain %EWL were 81 kg (63-90), 30.3 kg/m2 (24.5-37), and 59.3% (12.9- Methods: Video presentation illustrares the laparoscopic techniqe of 82.3) respectively. During follow-up, 1 patient underwent to second V.B.G.to R-Y gastric bypass. step of DS. Results: All 12 patients converted were relieved of their symptoms Conclusion: Laparoscopic conversion of RYGB to SG is feasible of band obstruction and achieved good weight loss. and safe. Development of gastric fistula is a concern. After Conclusion: Conversion of V.B.G to R-Y gastric bypass may deem conversion, weight loss is increased, which leaves the patients in to be necessary to relieve the patients symptoms from band better conditions for undergoing the second step of DS. obstruction and to maintain weight loss.

V-006 Laparoscopic Gastric Bypass Technique Using Anterior V-008 Trans-Umbilical Gastric Band Placement: Single-Port Approach To Ligament Of Treitz Vs. Multiple-Port

PRESENTER: Gordon Wisbach (Naval Medical Center San PRESENTER: Carlos Galvani (University of Arizona) Diego) Co-authors: Maria Gorodner2, Alberto Gallo2, Albert Amini1 facilitate the procedure.

1. Surgery, University of Arizona, Tucson, AZ, United States. 2. Surgery , University of Illinois, Chicago, IL, United States. V-010 Single-Incision Laparoscopic Adjustable Gastric Band Placement (SI-LAGB) and Hiatal Hernia Repair. Background: Single-access surgery has emerged as an attempt to decrease incisional morbidity and enhance cosmetic benefits. PRESENTER: Carlos Galvani (University of Arizona) Nevertheless, the application of single incision techniques in the field of bariatric surgery has yet to be established. Herein, we Co-authors: Maria Gorodner2, Alberto Gallo2, Albert Amini1 present two cases of trans-umbilical gastric band placement using two different techniques to access the abdominal cavity. 1. Surgery, University of Arizona, Tucson, AZ, United States. Methods: Case # 1: 27-year-old AA female, 66.00 in. tall, 249.0 lb , 2. Surgery , university of Illinois, Chicago, IL, United States. with a BMI of 40.2 kg/m2. Her comorbidities were Gastroesophageal Reflux, and menstrual Irregularity. Her past surgical history was unremarkable. A commercially available Background: SI-LAGB has demonstrated to be safe and feasible. single-port was used, with two 5mm and one 15mm trocars. The presence of concomitant hiatus hernia requires simultaneous Case # 2: 68-year-old female, 65.00 in., and 295.0 lb., with a BMI repair. Concern has been raised about satisfactory crural repair with of 49.1 kg/m2. Co-Morbidities were Hypertension, Dyslipidemia, the single-incision approach. Herein, we present a case of SI-LAGB Osteoarthritis. Her surgical history was remarkable for Trans- with concurrent hiatal hernia repair. (HHR) vaginal hysterectomy. Two 5mm and one 15mm trocars were used. Methods: 50-year-old female with 14-years history of morbid Results: Case # 1; Single port trans-umbilical gastric band obesity. Complaining of constant heartburn and regurgitation. No placement was performed. The patient had uneventful postoperative dysphagia or chest pain. BMI: 36 kg/m2 recovery. She was discharged 3.5hs after surgery. Operative time PMH: Hypertension, Hyperthyroidism, gastroesophageal reflux was 43 min, blood loss minimal. No perioperative complications disease. PSH: C- section, Knee surgery observed. Preoperative barium swallow demonstrated sliding hiatal hernia. A Case # 2; Multiple port trans-umbilical gastric band placement was single incision was made for the combined procedure. Two 5-mm performed. The patient had uneventful postoperative recovery. She and one 15-mm trocar were used. The device for retraction was discharged 3 hs after surgery. Operative time was 34 min, blood consisted of a laparoscopic bulldog clamp attached to an elastic stay loss minimal. No perioperative complications observed. hook. Conclusion: Both access techniques were safe. Trans-umbilical Results: patient underwent SI-LAGB and HHR. Posterior crura gastric band placement is feasible, and can be performed without closure was performed. Operative time was 50 minutes; estimated changing existing principles in gastric band. The single port blood loss was 10 cc, and hospital stay 4 hours. No Perioperative technique may require extra time for insertion and closure of the complications were observed. abdominal wall. Conclusion: SI-LAGB and HHR can be performed safely without increasing complication rate. Therefore, liberal repair is recommended whenever hiatal hernia is diagnosed.

V-009 Single Port Sleeve Gastrectomy (Sg) And Hiatal Hernia

Repair V-011 The Case Of The Missing Roux Limb

PRESENTER: Carlos Galvani (University of Arizona) PRESENTER: Susannah Wyles (Imperial College Healthcare) Co-authors: Maria Gorodner2, Alberto Gallo2, Albert Amini1 Co-authors: Sherif Hakky1, Ahmed R. Ahmed1

1. Surgery, University of Arizona, Tucson, AZ, United States. 1. Imperial College Healthcare, London, United Kingdom. 2. surgery , university of Illinois, chicago, IL, United States.

Background: The case is a 49 year old lady who underwent a Background: Standard laparoscopic SG has demonstrated to be safe. laparoscopic Roux-en-Y gastric bypass in 2005. In December 2008 The presence of hiatal hernia has been considered a contraindication she developed abdominal pain that became increasingly severe. In SG. The introduction of single incision techniques in bariatric February 2009 she presented to her local hospital with an acute surgery is still controversial. Herein we present a case of Single port abdomen and was taken to the emergency operating room. At SG and hiatal hernia repair (HHR). operation she was found to have an internal hernia and a totally Methods: 36 yo female with a BMI of 47 kg/m2, presenting for necrotic Roux limb, which was excised in its entirety. She had a evaluation and treatment of morbid obesity. Her past medical feeding jejunostomy tube placed at this time and was made nil by history was significant for gastroesophageal reflux disease, mouth. She continued to lose weight and was referred to our team. osteoarthritis, hypertension and sleep apnea. Her past surgical She was started on total parenteral nutrition in addition to her history was significant for hip replacement. The device for liver jejunostomy feeds, and having gained 5kg she underwent surgery retraction consisted of a laparoscopic bulldog clamp attached to an with a plan to restore her gastro-intestinal tract continuity. elastic stay hook. Methods: Through a midline laparotomy incision the significant Results: Patient underwent single port SG and HHR, through a 4-cm adhesions between the gastric pouch and the liver were taken down. incision, located left and superior to the umbilicus using a 12-mm Having placed a 34Fr Oro-Gastric tube and a Penrose drain to help and two 5-mm trocars inserted through a a commercially available identify the pouch, this was separated from the gastric remnant. single-port device. Operative time was 92 minutes; estimated blood After small bowel adhesiolysis and careful measurement of the loss was 10 cc, and hospital stay 2 days. No Perioperative common channel it was decided that forming a new Roux limb complications were observed. would render the common channel too short. Gastro-Intestinal Conclusion: Single port SG it is feasible. Simultaneous HHR should continuity was re-established via a side-to-side gastrogastrostomy. be performed if hiatal hernia is diagnosed. Adequate exposure of the Results: The patient made an uneventful recovery and on day seven gastroesophageal junction and esophageal hiatus is necessary to post-op was discharged home on a liquid diet. V-013 Minimally Invasive Paraesophageal Hernia Repair with Conclusion: Internal hernia can lead to the complete loss of the Sleeve Gastrectomy Roux limb. Reversing the bypass is a feasible and effective treatment option. PRESENTER: Chirag Dholakia (UC Irvine Medical Center)

1 1 Co-authors: Kevin M. Reavis , Johnathan A. Slone , Ninh T. 1 V-012 Gastric Banding: A Point Of No Return? Nguyen

PRESENTER: Susannah Wyles (Imperial College Healthcare) 1. General Surgery, UC Irvine Medical Center, Orange, CA, United States. 1 1 Co-authors: Sherif Hakky , Ahmed R. Ahmed Background: Laparoscopic repair of large paraesophageal hiatal 1. Imperial College Healthcare, London, United Kingdom. hernias is challenging and can be associated with a high rate of recurrence. Reduction and repair of the paraesophageal hernia Background: Laparoscopic adjustable gastric banding has become accompanied by a sleeve gastrectomy may minimize the liklihood an increasingly common procedure since its introduction in 1993. of recurrence. We present a case of laparoscopic reduction of Although relatively easy to place, revision surgery can be complex paraesophageal hernia accompanied by a sleeve gastrectomy. and challenging. We present two cases where the patients had Methods: Our patient is a 60 year old male who presented with a variable symptoms some time after gastric banding and were long history of epigastric pain, severe obesity (BMI 38) and managed in different ways. The aim was to provide solutions for gastroesophageal reflux. Endoscopy revealed a large hiatal hernia other less experienced multi-disciplinary teams who might have and the upper GI contrast study showed an 8 cm type II gaps in their expertise. paraesophageal hernia. The patient underwent a laparoscopic Methods: Case one was a 43 year old female who had a band placed reduction of the paraesophageal hernia with a crural closure using 3 years ago and failed to lose weight despite adequate restriction. pledgeted sutures followed by a sleeve gastrectomy over a 32Fr She proceeded to laparoscopic adhesiolysis, band removal and bougie. conversion to a Roux-en-Y gastric bypass since she also had Results: The operative time was 2 hours. Post-operatively, the upper significant obesity-related co-morbidities. The second case had a GI contrast study showed complete reduction of the paraesophageal band placed in 2007. She too failed to lose significant weight and hernia and smooth contrast flow through the gastric sleeve. There proceeded to a laparoscopic band removal and conversion to sleeve were no postoperative complications. Four months following gastrectomy. surgery the patient's BMI had reduced to 31 and he was free of Results: Both cases demonstrated on the video made uneventful antireflux medication recoveries and have proceeded to lose weight. This is supported by Conclusion: Paraesophageal hernia repair accompanied by sleeve the current published case series in the literature (See Table). gastrectomy is an acceptable and effective means of providing Conclusion: Although easy to place, adjustable gastric banding can definitive repair along with weight loss and potentially reducing risk become challenging when attempting removal or revision. However factors associated with hernia recurrence. with the appropriate expertise this can be achieved laparoscopically with no detrimental consequences to the patient.

Published data for patient outcome after Gastric Band laparoscopic revisional surgery V-014 A New Approach For Leak After Sleeve Gastrectomy-A Unique Case Report Mean Pre- weight No. Mobidity Procedure Op Mortality loss at PRESENTER: Shashank Shah (Ruby Hall Clinic) Patients Major/Minor BMI 6,12,18 1 1 months Co-authors: Jayashree S. Todkar , Poonam S. Shah

Band to 1. Surgery, Ruby Hall Clinic, Pune, Maharashtra, India. Roux-en-Y Gastric 50, 59.5, 44.9 Bypass 70.2 Background: Leaks is the most dreaded complication of sleeve 70 926.9- 3/7 0 (Mognol, (EWL gastrectomy (SG). The video demonstrates a novel approach to treat 81) 2004, %) such leaks which may reduce the morbidity of this complication. Obesity Methods: A 36 years old female with BMI 42 kg/m2 and impaired Surgery) glucose tolerance, hypertension , sleep apnea, underwent standard Laparoscopic sleeve gastrectomy She presented with mild Band to tachycardia, with abdominal distention after 48 hours.. CT scan of Sleeve the abdomen showed no collection, but leak of contrast and and gas Gastrectomy 38.66 48.3, under diaphragm. Laparoscopic lavage and adhesionolysis revealed (Acholonu, 15 (29.7- 2/0 0 57.2, leak near the oesophago-gastric junction. The leak site was sutured 2009, 49.3) 60.1 (lb) with 2 „0‟ vicryl,3 interrupted sutures with omental patch. Obesity Endoscopy was performed and air leak test was done to confirm Surgery) integrity of the closure and endoluminal stent was placed.

Results: Gastrograffin swallow after 24 hrs confirmed no leak. Patient was started with oral liquids and was discharged on 4th day. Stent was removed after 3 weeks. Patient had an uneventful recovery. Conclusion: Intra operative leak test may remain fallacious to amongst the most frequent causes. diagnose leaks. An aggressive timely approach with primary closure Methods: We present a 75-year-old female, BMI – 36.36, status post of leak and simultaneous endoluminal stent could be a better placement of a LAGB 5 years before consultation in an outside approach to deal with immediate post operative leaks after SG. institution presenting with episodic vomiting and epigastric pain of a few weeks duration. An upper GI performed showed a HH and a

possible BS. Results: The patient underwent a laparoscopic HH repair and V-016 Laparoscopic Seromyotomy As A Treatment Option For repositioning of the LAGB. Gastric Outlet Obstruction After Laparoscopic Sleeve Upper GI series on first post op showed the gastric band in Gastrectomy For Morbid Obesity satisfactory position and adequate emptying from the esophagus into the stomach and duodenum. There was no leak or obstruction. The PRESENTER: Ismael Court (Cleveland Clinic Florida) postoperative period was uneventful. The patient was commenced on a bariatric clear liquid diet, and discharged home on POD #2. Co-authors: Omar Bellorin 1, Adeshola Fakulujo 1, Samuel Samuel 1 1 Conclusion: Simultaneous HH and BS is an unusual clinical Szomstein , Raul J. Rosenthal presentation. Laparoscopic repair and repositioning appears to be a safe and feasible treatment option. 1. Bariatric, Cleveland Clinic Florida , Weston, FL, United States.

Background: This video illustrates the use of laparoscopic V-018 Laparoscopic Conversion Of Sleeve Gastrectomy To techniques to resolve a gastric outlet obstruction two months after a Roux-En-Y Gastric Bypass For Acute Gastric Outlet laparoscopic sleeve gastrectomy (LSG) done for morbid obesity. Obstruction After Laparoscopic Sleeve Gastrectomy For Methods: A sixty six-year-old female two months status post a LSG Morbid Obesity. for morbid obesity, who presents with new onset of progressive dysphagia. After the original LSG, the patient did well postoperatively. On postoperative day one, upper GI with PRESENTER: Omar Bellorin (Cleveland Clinic Florida) Gastrografin (UGI) study showed evidence of an adequate passage Co-authors: Ismael A. Court1, Jayne Lieb1, Samuel Szomstein 1, of contrast in to the duodenum, being the patient discharged home Raul J. Rosenthal 1 uneventfully. Two months after surgery, the patient was admitted with severe dysphagia. The repeated UGI showing evidence of a narrow sleeve with what appears to be a kink on the upper third with 1. Cleveland Clinic Florida, Weston, FL, United States. mild-to-minimal passage of contrast and delay of emptying from the esophagus. Endoscopy was performed that showed also evidence of kink in the upper third of the sleeve. The patient underwent a Background: This video illustrates the laparoscopic conversion of diagnostic laparoscopy. During the procedure dense omental sleeve gastrectomy to Roux-en-Y gastric bypass as a treatment adhesions were taken down, identifying a kinked area on the upper option for acute gastric outlet obstruction after laparoscopic sleeve third of the sleeve that was possible due to scar tissue. The surgery gastrectomy for morbid obesity. proceeded performing a seromyotomy from the distal end of the Methods: A 29 year old male with a previous surgical history of esophagus into the sleeve to a point about 4-5 cm distal from the band removal for erosion is 5 days status post sleeve gastrectomy. area of obstruction. The patient developed persisting nausea, vomiting, burping, and Results: A CT scan showed a collection at the upper left quadrant. high-grade dysphagia. An upper GI series showed a blockage of The patient underwent a diagnostic laparoscopy and a laparoscopic contrast material going into the distal stomach. The decision was drainage of the collection at postoperative day one. The patient did made to perform a diagnostic laparoscopy. The liver is cranially well postoperatively. The patient was started on oral feeds on retracted, the sleeve identified. An EGD is performed postoperative day # 3 and was discharged home on postoperative intraoperatively that shows a complete obstruction at the proximal day #10. The long-term follow-up and recovery were uneventful. midportion of the gastric sleeve in the area where the staple line had Conclusion: Sleeve outlet obstruction after LSG is an unusual to be oversewn due to staple line dehiscence. At this point, the complication. The laparoscopic approach and gastric seromyotomy decision is made to proceed to conversion to a gastric bypass. An is a feasible option in the management of this complication antecolic, antegastric, Roux-en-Y gastric bypass with a 100 cm alimentary limb and 50 cm biliopancreatic limb, and resection of the

distal stomach was performed. V-017 Laparoscopic Repair Of Hiatal Hernia And Band Results: The patient tolerated the procedure well. The postoperative Slippage For Intractable Gastroesophageal Reflux Disease And period was unremarkable and the patient was discharged home on Dysphagia. postoperative day 4 tolerating PO diet. Conclusion: Sleeve outlet obstruction after LSG is an unusual complication. The laparoscopic approach and conversion to Roux- PRESENTER: Raul Rosenthal (Cleveland Clinic Florida) en Y gastric is a feasible option in the management of this complication Co-authors: Adeshola Fakulujo 1, Omar Bellorin 1, Ismael A. Court1, Samuel Szomstein 1

1. Cleveland Clinic Florida, Weston, FL, United States. V-019 Laparoscopic Transection Of Gastro-Gastric Fistula And Oversewing Of Gastric Remnant And Pouch

Background: Motility disorders in the morbidly obese (MO) population are reported to be as high as 40%. Laparoscopic PRESENTER: Omar Bellorin (Cleveland Clinic Florida) adjustable gastric banding (LAGB) is a popular and accepted surgical treatment option for MO. Gastroesophageal reflux (GERD) Co-authors: Ismael A. Court1, Adeshola Fakulujo 1, Samuel is in most cases a sign of a mechanical complication following Szomstein 1, Raul J. Rosenthal 1 LAGB. Undetected hiatal hernias (HH) and band slippages (BS) are 1. Cleveland Clinic Florida, Weston, FL, United States.

Background: The use of laparoscopic techniques in the management of gastro-gastric fistula is not studied well. Methods: A 55-year-old female with a history of gastric bypass for failed laparoscopic adjustable gastric banding complains of dysphagia and recurrent upper abdominal pain when swallowing solids. Upper GI shows a gastro-gastric fistula with significant contrast extending from the gastric pouch into the bypassed gastric remnant. Results: The patient underwent a laparoscopic revision. A gastro- gastric fistulous tract was dissected and divided. The gastric pouch and gastric remnant staple lines were oversewn. Postoperative upper GI showed an intact gastric pouch with no evidence of extraluminal leak, gastro-gastric fistula, or obstruction. The patient was discharged on postoperative day five tolerating soft mechanical diet. Conclusion: Laparoscopic transection of gastrogastric fistula and oversewing of gastric remnant and pouch appears to be safe and feasible.

P-001 Laparoscopic Duodeno-Jejunal Bypass with Sleeve was 3.5 days (range 2-5 days). Additional port used to retract liver Gastrectomy – a Modified Duodenal switch technique: and that was subsequently used for drain placement. There was no Preliminary Result Of New Technique From India conversion, morbidity and mortality. Conclusion: Single-incision laparoscopic sleeve gastrectomy is PRESENTER: Mahendra Narwaria (Asian Surgicentre) technically feasible option.

Co-author: Avinash K. Tank1 P-003 Swedish Adjustable Gastric Banding: 10 Years Experience

1. Bariatric and Advanced G.I.Laparoscopic Surgery, Asian Surgicentre, Ahmedabad, India. PRESENTER: Reinhard Mittermair (Medical University Innsbruck)

Background: Obesity and metabolic diseases are emerging as health- Co-authors: Johann Pratschke1 problem in India. Low intake of protein diet in Indian vegetarian food make them vulnerable for protein malnutrition after Roux-en-y Gastric Bypass (RYGB). We introduced a new procedure for 1. Surgery, Medical University Innsbruck, Innsbruck, Austria. morbidly obese diabetic vegetarian patients from India. Instead of Roux-en-Y gastric bypass (RYGB) we did modification of this Background: Bariatric surgery is currently the only effective duodenal switch technique - laparoscopic duodenojejunal bypass with treatment for morbid obesity. Few long-term studies on Swedish sleeve gastrectomy (LDJB+SG) in our patients. adjustable gastric banding (SAGB) have been published. We here Methods: Initially stomach & duodenum is mobilized and first part of report our 10-year experience with 785 SAGB procedures. duodenum is divided. DJB was done with 50 cm of biliopancreatic Methods: Between January 1996 and January 2006, 785 consecutive limb and 150-200 cm of alimentary limb. Stappled jejuno- patients (81% women, 19% men) underwent laparoscopic SAGB. jejunostomy was performed and then end to side hand sewn two The postoperative follow-up program was performed largely by layered duodeno-jejunostomy was done. Sleeve gastrectomy was residents while 30 different surgeons performed the operation. performed after keeping endoscope along lesser curve of stomach Results: Follow up data were available for 733 patients (98.3%); 52 Results: Twenty three patients underwent LDJB+SG between June patients (6.6%) were lost to follow-up. The median total weight loss 2008 to Sept 2009. There were 7 male and 16 female patients. Mean was 26 kg after 1 year and 40.5 kg after 8 years with a median EWL BMI was 40.67 kg/m2 (range 30.7–70.2). Mean operating time was of 65.5% after 8 years. The median BMI decreased from 42.9 to 28.3 192 min (range 90-240 min). Mean hospital stay was 3 days (range 3 - kg/m(2). A total number of 688 complications occurred in 396 5 days). There was no conversion and mortality. One major patients (50.4%). The most common complications were esophagitis anastomotic leak from sleeve which required re-laparoscopy and (28.8%), pouch dilation (15.3%), esophageal dilation (12.5%), port drainage and healed in 3 weeks and one duodenal stump leaked after problems (11%), band migration (6.5%), and band leakage (6.4%). 10 days which required radiological drainage and healed in 4 week. Furthermore, we found that, 57% of our complications were There was no nutritional complication happened during follow-up. associated with esophagitis, esophageal dilation, and pouch dilation. Most of associated co-morbidities were resolved. Overall, 251 reoperations (32%) were performed. There was no Conclusion: LDJB+SG is safe and effective procedure for the weight mortality. loss, resolution of co-morbidities and to preserve protein mass of Conclusion: On the basis of our experience, we recommend the body. following basic criteria for patient selection for Swedish adjustable band placement: As a means of reducing the high complication and reoperation rate, preoperative esophageal manometry is a valuable P-002 Single Incision Trans-umbilical Laparoscopic Sleeve instrument in identifying poor esophageal body motiliy. In this case Gastrectomy:Early results from India gastric banding should not be performed and we recommend the RY gastric bypass. Likewise, as recommended for more invasive bariatric procedures, the SAGB operation and the follow-up should PRESENTER: Mahendra Narwaria (Asian Surgicentre) only be performed by a team of experienced bariatric surgeons.

Co-Authors:, Avinash K. Tank1 P-004 Is It Really Necessary To Close Mesenteric Defects

Undergoing Laparoscopic Roux-en-Y Gastric Bypass Surgery? – 1. Bariatric and Advanced G.I.Laproscopic Surgery, Asian Case Report And Review Of The Literature Surgicentre, Ahmedabad, Gujarat, India.

PRESENTER: Reinhard Mittermair (Medical University Background: Laparoscopic sleeve gastrectomy is a preferred Innsbruck) bariatric procedure. Recent technical innovation has made it possible to perform this procedure with single trans-umbilical incision. Co-authors: Johann Pratschke1 Methods: Technique: Patient is positioned in supine position and surgeon stands between the legs. A 2 cm long vertical incision is given to umbilicus and 1. Surgery, Medical University Innsbruck, Innsbruck, Austria. deepened till peritoneum and flexible port (SILSTMPort, Covidien) is placed and then procedure is performed with same principle of conventional laparoscopy, using roticulator instruments. Background: Laparoscopic Roux-en-Y gastric bypass surgery Materials and Methods: Fourteen patients underwent laparoscopic reportedly has a higher rate of postoperative internal hernias than trans-umbilical sleeve gastrectomy by single surgeon (MN) using open bypass surgery. Even with closure of mesenteric defects, single trans-umbilical incision during September 2009– to February hernias occur in up to 9% of cases (Petersen‘s defect and the 2010. jejunojejunostomy). The rate of internal hernias was compared Results: Mean age was 34 years (range 20-50). All patients were among patients undergoing laparoscopic Roux-en-Y gastric bypass female. Mean BMI was 38.28 kg/m2 (range 33.5 to 45.8). Mean surgery using the retrocolic and antecolic approaches with and operating time was 165 min (range 120-210 min). Mean hospital stay without closure of mesenteric defects. Methods: We report a 38-year-old woman with an internal hernia and a necrotic small bowel and a postoperative small bowel Background: Laparoscopic Sleeve Gastrectmy is a new option in obstruction. The necrotic small bowel had been resected and a new surgical weight loss and shown to have superior results when Roux-en-Y had been performed. The mesenteric defects had not compared to Adjustable Gastric Banding. The higher complication been closed when the Roux-en-Y gastric bypass was performed rate is a major concern for morbidity and mortality in this high risk primarily. group. Results: Review of the literature: the antecolic antegastric approach Methods: The data for 50 patients who had their VSG performed by a to laparoscopic Roux-en-Y gastric bypass is associated with fewer single surgeon between 2007-2008 were retrieved. We report the pre postoperative hernias than the retrocolic retrogastric approach. The and post surgical BMI, % excess weight loss (%EWL) over 6 months frequency of hernias using either technique is low if meticulous and 12 months period and major complications including leak, attention is paid to closure of all mesenteric defects. stenosis, bleeding and mortality. All cases were performed Conclusion: Closure of mesenteric defects with non-absorbable laparoscopically, using a 34 French bougie, with stapling of greater running suture and antecolic Roux limb are recommended. curvature starting 5cm away from the pylorus. The dissection of stomach was in a lateral to medial technique. A Methylene blue leak test at the end of the procedure and a Gastro-grafin swallow study on P-005 One-Year Interim Results of LAP-BAND AP® post-operative day number one was used to document the integrity of EXperience (APEX) Study in the “Super-Obese”: A Prospective, the staple line. Also staple lines were re-enforced using buttress Multi-Center Longitudinal Patient Observational Study material to reduce the possibility of post-op bleeding. Results: There was 3 Mortalities which is thought to be due to our selection of high risk patients for this procedure (Two Cardiac events, PRESENTER: Brad Watkins (Cincinnati Weight Loss Centre) one ischemic bowel). There was 3 leaks (6%), No stenosis, no bleeding documented. Co-authors: Kevin Montgomery2, Michael G. Oefelein3 43 patients(84.3%)had a one year follow up:% EWL 62.06

Conclusion: Contrary to previous believe, we hypothesize that higher 1. Surgery, Cincinnati Weight Loss Centre, West Chester, OH, leak rate is not due to a longer staple line, but due to increased United States. pressure at the proximal part of the sleeve. This was noted due the 2. Surgery, Northwest Weight Loss Surgery, Everett, WA, United fact that most of the leaks after Sleeve Gastrectomy are seen in the States. proximity of the Gastro-Esophageal junction. Our study had over 3. Health-Bariatrics, Allergan, Irvine, CA, United States. 60% EWL after 12 months.

Background: Bariatric surgery has been established as an effective treatment to reduce weight in severely obese patients (> 40 kg/m2 OR > 35 kg/m2 with > one co-morbidities) refractory to behavioral P-007 Trans-Umbilical Two-Site Laparoscopic Bariatric Surgery and medical therapies. The purpose of this study is to summarize the In Super-Morbid Obese Patients 1-year interim safety and efficacy of the LAP-BAND AP® System (AP Band, Allergan, Irvine, CA) in patients with a baseline BMI > PRESENTER: Wei Lee (Min-Sheng General Hospital) 50kg/m2. Co-Authors: Jung-Chien Chen1, Kong-Han Ser1, Yen-How Su1, Jun- Methods: This is an ongoing 5-year, prospective, open-label, multi- 1 1 1 center study which will assess weight reduction, co-morbidities and Juin Tsou , Yi-Chih Lee , Shu-Chu Chen health related-quality of life PRO after implantation of the AP Band. This is an interim analysis of patients (n=58) with BMI greater than 1. Surgery, Min-Sheng General Hospital, Taoyuan, Taiwan. 50 kg/m2 who have completed the 1 year post-operative scheduled visit. Weight loss and % excessive weight loss (%EWL) from Background: Single incision laparosopic surgery (SILS) has emerged baseline are the primary efficacy end-points and adverse events (AE) recently but is very difficult to be applied in super-morbid obesity are the primary safety end-point. patients. Here, we introduce the 2-incision technique for laparoscopic Results: At baseline, 58 of the 323 (18%) enrolled patients had a bariatric surgery (LBS) and report our first 19 consecutive patients. baseline BMI > 50kg/m2 (range 50-66kg/m2). The baseline excess Methods: We use 2 skin incisions at umbilical site to place two weight was 191 lbs and the %EWL was 24% at Week 24 36% at trocars (12mm, and 10 mm) for video port and working port for Week 48. The interim safety assessment identified 15 AEs and 2 stapler. Another 5 mm working port was placed at left abdomen. SAEs. No band erosions or reoperations were reported. The 2 SAEs Using these 3 ports, we can use conventional laparoscopic involved an antibiotic reaction and a micro-discectomy for herniated instruments to performed LBS. The data from 19 consecutive 2-site disc—both considered unrelated to the intervention. LBS (18 bypass and 1 sleeve) from February 2009 to Sep 2009 were Conclusion: The 1-year interim APEX trial results support the safety compared with another 19 matched consecutive patients with and efficacy of the LAP-BAND AP® system for bariatric standard 5-site LBS from Nov 2008 to Jan 2009. management in a population at high risk for surgical complications-- Results: The mean BMI was 54.6 kg/m2 and mean age 28.0 years. the super obese (BMI > 50 kg/m2). The procedures were successfully performed in all patients but 2 patients required extra skin incision for 5mm port to complete the procedures. Mean operating time was 167.9 min (115-190). Mean P-006 One Year Result of Laparoscopic Sleeve Gastrectomy, blood loss was 57.9 ml (20-150) and hospital stay was 4.7 days (3-9 Retrospective review of 50 Cases ). No major complication but 1 patient (5.3%) had minor complications. The mean operating time was significantly increased

(167.9 vs. 131.2 min, P <0.05) in the 2-site LBS, but 2-site LBS PRESENTER: H. Joseph Naim (Advance Bariatric Center) group had less pain, shorter hospital stay (4.7 vs. 6.0 days; p<0.05) Co-Authors: Mathias A. Fobi2, Chi-kekah Che-senge2, Leenoy and better cosmetic satisfactory results comparing to conventional Hendizadeh2 LBS group. Conclusion: Two-site LBS is a feasible modified SILS for bariatric procedure of super-morbid obesity. 1. Advance Bariatric Center, Los Angeles, CA, United States. 2. Surgery, St. Mary Medical Center, Long Beach, CA, United States.

Stenosis/Dilation of the Control

P-008 Bariatric Surgery Utilization Rates Following Surgery GJ Group Coverage by an Employee-based Healthcare System Male/Female 4/8 3/9

PRESENTER: Keith Kim (Florida Hospital Celebration Health) Mean Age ± SD, years 47±11 38±12 Preoperative BMI, 1 1 41±3 43±5 Co-authors: Vickie White , Cynthia K. Buffington Kg/m2

1.Metabolic Medicine and Surgery Institute, Florida Hospital Excess Weight Loss, % 82±26 81±17 Celebration Health, Celebration, FL, United States. Pouch Area, cm2

1 Day After Surgery 22±9 23±9 Background: Incidence rates for obesity co-morbidities are high for individuals with Class III, morbid obesity. Bariatric surgery At Follow-up* 37±16 22±9 resolves/improves these co-morbidities, along with reduction in GJ Diameter, cm healthcare costs. Despite surgery benefits, payors are reluctant to 1 Day After Surgery* 1.0±0.4 0.7±0.2 provide coverage for fear of increased demand and costs. This study examines surgery utilization rates following coverage by an At follow-up 1.1±0.2 1.0±0.3 employee-based healthcare system. Methods: Bariatric surgery utilization was provided by an employee- based healthcare system for a period including one year before * p<0.05 (t-test) bariatric surgery coverage and one year following. Utilization rates were calculated from the numbers of employees eligible for surgery. Results: The data show a utilization rate of 1.71% in the year prior to P-010 A Survey On The Use Of Prophylaxis Against Venous healthcare coverage. In the year following bariatric surgery coverage, Thrombolembolic Disease And Peptic Ulceration Amongst the utilization rate remained essentially unchanged, i.e. 1.42%. Members Of The British Obesity And Metabolic Surgery Society Conclusion: These findings should help to dispel the notion by (BOMSS). employee-based insurers that coverage of bariatric surgery will lead to high utilization and associated costs in the early post-coverage PRESENTER: Dugal Heath (Whittington Hospital) period. Co-authors: Kirsten McDougall1, Lucy Jones1, Sufi Pratik1

P-009 Impact of dilation of gastrojejunostomy strictures after 1. Bariatric surgery, Whittington Hospital, London, United Kingdom. Laparoscopic Youx-en-Y Gastric Bypass (LRYGB) on weight loss and gastric pouch anatomy. Background: Venous thromboembolism (VTE) represents a significant cause of mortality and morbidity and peptic ulceration PRESENTER: Miguel Herrera (ABC Medical Center) occurs in 15% of patients post Roux-en-Y gastric bypass (RYGB). There are no national guidelines regarding prophylaxis. Co-authors: Jorge Gonzalez1, Rocio Perez-Johnston2, Claudia Methods: In this study we examine the current practice of BOMSS Hernandez2, Marco Teliz2, Maureen Mosti1, Jorge Ibarra1, Arturo members regarding prophylaxis against VTE and peptic ulceration Rodriguez1, Miguel F. Herrera1 through a survey of members Results: Results: Twenty one (20%) surgeons replied. All employed 1. Obesity Clinic, ABC Medical Center, Mexico, Mexico. low molecular weight heparin (LMWH) and all except one (5%) 2. Radiology Department, ABC Medical Center, Mexico, Mexico. antiembolic stockings. Two (11%) did not use intermittent calf compression. LMWH was started postoperatively by 2 (11%) with the remainder (19, 89%) being started intraoperatively or Background: Stricture of the gastrojejunostomy (GJ) is a common postoperatively. Standard and high doses of LMWH were used by 3 complication of LRYGB. Most strictures are successfully treated by (14%) and 18 (86%) respectively. Eight (38%) discontinued LMWH endoscopic balloon dilation. Enlargement of the gastric outlet may on discharge with 13 (62%) prescribing it for a median of 2 weeks have a deleterious impact. The aim of the study is to analyze the (range 1 to 6 weeks). Eleven (52%) discontinued antiembolic impact of GJ dilation on weight loss, pouch area and GJ diameter. stockings on discharge with 10 (48%) prescribing it for a median of 2 Methods: From a total of 28 patients who developed stenosis of the weeks (range 1 to 6 weeks). Nine (43%) employed intermittent calf GJ after LRYGB ia a 4-year period, 12 patients accepted to compression in theatre, one (5%) overnight following surgery, eight participate in the study. A group of 12 matched controls were (38%) until the patient was mobile, and three (14%) until discharge. selected for comparison. Patients underwent an upper gastrointestinal 19 (90%) employed proton pump inhibitors as prophylaxis against radiological study using gastrographin. Pouch area and diameter of peptic ulceration following RYGB. One (5%) did not use prophylaxis the GJ were measured and weight loss was evaluated at the time of and one (5%) employed H2 antagonists. The median duration of the study. treatment was three months (range 2 weeks to lifelong). Results: Both groups were comparable in terms of demographic Conclusion: Further study is required to identify the most appropriate characteristics. The time between the surgical procedure and the regime to prevent VTE and peptic ulceration post RYGB. presence of the GJ stricture was 61.8±31 days. All patients were successfully treated by a single balloon dilatation up to 15-20 mm. Mean follow-up in the group of cases was 27±7 and in the control P-011 Use Of Dilating Tip Trocars Decrease The Incidence Of group 30±8 months. Trocar Site Hernia In Bariatric Surgery Conclusion: Endoscopic balloon dilation of GJ strictures does not have deleterious impact on weight loss and permanent GJ diameter. PRESENTER: Jayaraj Salimath (Methodist Medical Center of RESULTS Illinois) 1. Surgery, Methodist Medical Center of Illinois, Peoria, IL, United and type of treatment of DM2 with the degree of resolution of the States. disease after BAGUA. We find the same type of response of the DM2 to BAGUA in morbid obese than in non morbid obese operated for DM2. Background: Background: Trocar site hernia is rare but can be a devastating complication after laparoscopic surgery, especially in Bariatric surgery. Laparoscopic bariatric surgery has significantly P-013 Is There An Indication For Retrievable Cava Vein Filters reduced the incidence of incisional ventral hernia. This study In Morbid Obese Patients? evaluates the incidence of trocar site hernia after laparoscopic bariatric surgery with use of dilating tip trocars. Methods: We reviewed prospectively collected data of 136 patients PRESENTER: Amador García Ruiz De Gordejuela (Hospital who underwent Laparoscopic bariatric surgery. We use all dilating tip Universitari De Bellvitge) trocars, use four 12mm trocars and one 5mm trocar along with one Co-authors: Jordi Pujol Gebelli1, Enric Fernández Alsina1, Lluis 5mm incision for gastric bypass and sleeve gastrectomy. And two 1 1 5mm, one 12mm and one 15mm trocar for lap band. We close only Secanella Medayo , Carles Masdevall i Noguera 15mm trocar site fascia. Patients were evaluated clinically for any presence of trocar site hernia at 2 wk, 2 month, 6 month, 12 months 1. Servei de Cirurgia General, Hospital Universitari de Bellvitge , and annually. L'Hospitalet de Llobregat, Barcelona, Spain. Results: Out of 136 patients, 47 had Laparoscopic Roux-en-Y gastric bypass surgery, 61 had Laparoscopic Sleeve gastrectomy, 25 had Background: Although pulmonary embolism (PE) is a not a common Laparoscopic adjustable gastric banding and 3 had laparoscopic event, it is very difficult to diagnose and has a very high mortality revisional bariatric surgery. None of the 5mm trocar sites or 15mm rate. Some morbid obese patients have an increased risk of venous trocar sites had any hernia in lap band and bypass group. Only one embolism events due to their overweight and some of their out of 61 patient in sleeve gastrectomy group develops hernia at comorbidities. Retrievable cava vein filters (RCVF) have been specimen extraction site. Since then we are closing fascia at specimen proposed as an additional measure to prevent them. extraction site. Incidence of trocar site hernia in our group is 0.36%, Methods: We indicate RCVF prior to bariatric surgery in morbid which is statistically significant. obese patients who have increased thrombotic risk due to coagulation Conclusion: This study shows significant decrease of trocar site disturbances, and to patients with BMI over 60kg/m2 and severe hernia with use of dilating tip trocars in bariatric surgery sleep apnea. We review the patients who were indicated for a RCVF before bariatric surgery. We analyzed venous embolism events and morbidity related to the procedure and to the surgery. P-012 Diabetes Resolution In Morbid And Non Morbid Obese Results: We indicated a RCVF in 9 patients. All of them had a After One Anastomosis Gastric Bypass previous medical history of deep venous thrombosis (5), pulmonary embolism (2) or thrombophilia (2). All the filters were put 4 to 6 weeks prior to surgery and removed 1 to 5 months after the surgery. PRESENTER: Manuel Garciacaballero (University Malaga) We performed 6 gastric bypass, 2 duodenal switch and 1 sleeve gastrectomy. All the surgeries were done following our surgical Co-authors: Jose Manuel Martinez-Moreno1, Jose Maria Mata1, protocol. There was no morbidity related to neither the insertion nor Diego Osorio1, Alfredo Minguez1 the removal of the device. All the filters were removed. There was no

morbidity related to the surgery in these patients. While the patients 1. Surgery, University Malaga, Malaga, Spain. were the device just one patient had to be admitted due to a minor rectal bleeding. After 6 months of follow-up none of these patients Background: One of the most important challenge we have actually had a PE. in Diabetes Mellitus type 2 (DM2) surgery is to define in which Conclusion: Retrievable cava vein filters should be considered as a patients is indicated and what is the most efficient surgical procedure. prophylaxis in selected patients before bariatric surgery. Pulmonary We review our experience with One Anastomosis Gastric Bypass embolism can be effectively prevented with a low morbidity rate. (BAGUA) in the resolution of DM2. Methods: We review 236 morbid obese patients primary operated for weight loss and 5 non morbid obese operated for DM2. We evaluated P-014 Duodenal Switch to Treat Morbid Obesity in Prader-Willi age, BMI, waist circumference, familial history of DM2, time of Syndrome Patients evolution of DM2 and treatment, DM2 complications, HbA1c, comorbidities and quality of life (Euroqol 5 and Moorehead-Ardelt II PRESENTER: Barbara Metcalf (Pacific Laparoscopy) tests). And long term weight loss, evolution of DM2 treatment and complications and quality of life. Co-authors: John Rabkin1, Dana Benner1 Results: Only 19 from the 236 patients primary operated for weight loss were DM2 (8,05%). 69% were more than 50 years old, and the 1. Pacific Laparoscopy, San Francisco, CA, United States. rest less than 40 years old. Seven patients (37%) had insulin treatment, all of them had strong familial history of DM2 with severe complications. After BAGUA resolution of DM2 were 100% in those Background: Prader-Willi Syndrome (PWS) characterized by treated only with oral antidiabetic drugs, while all the patients under hyperphagia has been reported as the most common cause of genetic insulin treatment, although do not need more insulin, needed obesity associated with premature death. Dietary restriction and Metformin treatment after surgery. Of the 5 non morbid obese gastric restrictive procedures have been unable to produce sustained patients operated primary to treat their DM2, 3 were under insulin weight loss. We report on two PWS patients treated with the treatment and 2 need only oral antidiabetic drugs. After surgery they duodenal switch procedure (DS) for morbid obesity. behave in similar way as those operated primarily for weight loss Methods: A twenty-two year old male PWS (wt 334 lbs / BMI 48) from DM2 resolution. There were 5 surgical peri-operative major with co-morbidities including Type II diabetes mellitus, complications among obese patients operated for weight loss and hypertension, and sleep apnea and a ten year old female (wt 232 lbs / none among the DM2 patients. BMI 43) with co-morbidities including pre-diabetes, hypertension, Conclusion: We observed a direct relation between time of evolution asthma, and social isolation underwent laparoscopic DS. Both patients‘ families were directly involved in their care and the DS was supported by their pediatricians, endocrinologists, and psychologists. 1. Bariatric & Metabolic Surgery, St. Mary's Hospital, Seoul, Korea, Results: There were no operative complications. At four years post Republic of. DS the male patient weighs 180 lbs (BMI 25.5) and has sustained resolution of his obesity related co-morbidities. At five years post DS the female patient weighs 190lbs (BMI 34) has mild asthma, is active Background: Laparoscopic Roux-en Y Gastric Bypass surgery is socially with her non-affected peer group, and reports substantial being accepted as an effective treatment of obese patients, world improvement in her quality of life. Neither patient to date has widely. Especially it can lead not only to weight reduction, but also experienced any morbidity associated with the DS. has an improvement of comorbid condition associated with obesity. Conclusion: The DS which incorporates both restrictive and The treatment of morbid obesity using pharmacological methods and malabsorptive components to effect sustained weight loss offers PWS life style modification have limited outcome and their results are patients the best opportunity for weight loss maintenance long-term unsatisfactory. The aim of this study is to evaluate the improvement and permanent resolution of obesity related co-morbidities. The DS of glucose metabolism and surgical outcome of this method in also affords PWS patients a more normal eating pattern with reported morbidly obese patients with type II DM. improved quality of life for PWS patients as well as their families. Methods: From Sep. 2009 to Dec. 2009, 21 patients diagnosed Type II DM and morbid obesity underwent LRYGB surgery at the St.Mary hospital were recruited for this study. The clinical and anthropometric characteristics of patients prior to and 3months following LRYGB surgery, change of abdominal fat depot using by visceral fat CT scan, P-015 Achalasia And Morbid Obesity: Simultaneous operation time, post operative hospital stay were analyzed Management By Heller Myotomy And Gastric Bypass. retrospectively. Results: Among the 21 patients, the mean age of the patients was PRESENTER: Gustavo Pinto (Centro Integral de Tratamiento 45±9.8 and sex ratio was 1:1.625(male:female). Operation type was de la Obesidad) LRYGB surgery and there was no conversion to the open surgery. The mean operation time and the mean length of post-operative Co-authors: Jose Pestana1, Vittorio D'Andrea Marín1, Jose Gutierrez hospital stay were 260±62 minutes, 6.6±2.1 days, respectively. A few sendrea1, Francisco Obregon1 patients continued to take antihyperglycemic medication and most of patients stopped the medication or insulin.

Conclusion: According to our interim results, LRYGB surgery seems 1. Centro Integral de Tratamiento de la Obesidad, Caracas, to be an effective treatment modality of morbidly obese patients. Venezuela. Especially with type II DM, we might expect the remission of type II

DM and prevention of its complication. Longer follow up results will Background: Morbid obesity has become a major health problem all be needed to prove this. over the world and bariatric surgery offers a safe, effective and long lasting answer. The number of morbidly obese patients being referred for surgical treatment is increasing steadily. There are few reports of P-017 Does Lap-Banding Have a Future? evaluations of esophageal function in morbidly obese patients. Achalasia presenting in the context of morbid obesity is rare. Simultaneous management of both conditions is feasible and treats PRESENTER: Jerome Dargent (Clinique Lyon-Nord) both diseases in one operation Methods: A 49-year-old female patient with a BMI 51,11 and history Background: Lap-banding is still a good compromise in bariatric of obesity for several years presented with a 1 year history of surgery. Figuring its future, we have to take into consideration two dysphagia and regurgitation. Esophageal manometry, barium swallow key-concepts: 1. The position of a gastric band: the typical adjustable showed signs consistent with a diagnosis of Achalasia. Laparoscopic band placement below the GE junction; or as an outlet at the bottom anterior myotomy, extending 8 cms. up the distal esophagus and 2 of a gastric pouch created by stapling. 2. There are two ways to cms. along the gastric pouch combined with Roux-in-Y gastric address a time-frame in obesity surgery: The time that is available to bypass was performed. deliver its best effect regarding weight-loss; or the time that is Results: The patient did well and was discharged after 48 hours, and necessary in order to define a multiple-steps strategy. has been asymptomatic for 3 months. Actually her BMI is 37,3. A Methods: Non invasiveness is an important focus in bariatric surgery. barium esophagogram done three moths postoperatively We suggest starting with mixed procedures, using those with no demonstrated improvement of the esophageal dilatation and guarantee of long-term weight-maintenance, i.e. sleeve gastrectomy satisfactory emptying of the esophagus (SG) or intragastric balloon (IGB). Conclusion: Despite its association with other esophageal motility Results: I. Position of a band: A non invasive « band-like » procedure disorders, obesity is not generally considered a risk factor for can be worked out since we learned from the band that a connexion achalasia and the diagnosis of achalasia in the context of morbid exists between internal and external anatomy; we are currently testing obesity is rare. Diagnosis of this rare association between achalasia the sub-hiatal injection of Hyaluronic Acid, in combination with SG and morbid obesity is important to avoid the consequences of a or IGB. Likewise, we suggest making use of such an injection in misdiagnosis: worsening of the obesity if the myotomy is performed combination with endo-plication or endo-stapling devices such as alone or excessive weight loss if the bariatric procedure is performed those under investigation for the time being, which do not provide a alone. Simultaneous gastric bypass and Heller myotomy should be sufficient restriction at their outlet. the treatment of choice in this group of patients. II. A bariatric timetable: Any bariatric technique produces weight- loss within a limited period of time; therefore, careful consideration should be given to the choice of the least aggressive strategy. Conclusion: We suggest an incremental use of non invasive P-016 Change Of Glucose Metabolism And Visceral Fat Depot procedures, which could be followed by ―simple‖ current mini- After Roux-En Y Gastric Bypass Surgery invasive procedures, e.g. SG or lap-banding, the latter being a good candidate, since we reported good results of its use as a re-do after PRESENTER: Hongchan Lee (St. Mary's Hospital) VBG failures. Co-authors: Junsang Lee1, Eungkook Kim1 During the follow up, 22 patients (9.0%) experienced one or more complications. Band-related complications were observed in 12 patients (4.9%): slippage (n=5), intolerance (n=5), band erosion P-018 Comparison Of Adipocytokine Levels In Patients With (n=1), malfunction (n=1) and resulted in reoperation. Port revision Colorectal Carcinoma, Morbid Obesity And Control Group was performed in 9 patients (3.7%). One or more upper gastrointestinal symptoms were reported, at least one time, in 121 PRESENTER: Anna Maria Wolf (University Hospital Ulm) patients (50%). At 3 years, the mean BMI had significantly decreased from 42 to 31 Co-authors: Andreas Hillenbrand1, Juliane Fassler1, Hubert kg/m2; BMI was <35 kg/m2 in 77% of patients and <30 kg/m2 in Schrezenmeier2, Doris Henne-Bruns1, Uwe Knippschild1 47%; median excess weight loss and excess BMI loss were 61% and 66%, respectively; the prevalence of obesity-related comorbidities

had significantly decreased from 71% to 15%. Three patients 1. Dept. of General, Visceral and Transplantation Surgery, University underwent conversion to an alternative bariatric surgery. Hospital Ulm, Ulm, Germany. Ninety four percent of patients stated to be satisfied with the 2. Institute of Transfusion Medicine, University Hospital Ulm, Ulm, operation. QoL, significantly impaired preoperatively, improved Germany. dramatically during the first 6 postoperative months and reached

normal value at 1 year. Background: White adipose tissue has been recognized as an Conclusion: Gastric banding is a safe and efficient bariatric endocrine organ secreting a multiplicity of factors including procedure. adipocytokines. Obesity characterized by changed secretion of adipocytokines and inflammation is a risk factor for certain malignities. Here we investigate a possible relevance of P-020 Laparoscopic Sleeve Gastrectomy After Kidney-Pancreas adipocytokine profiles in patients with colorectal carcinoma (CRC), Transplantation In The Morbidly Obese: First Reported Case morbid obesity (MO) and control group, healthy blood donors (BD), And Literature Review in a gender-specific manner. Methods: Patient cohorts: 72 CRC patients (27 f, 45 m), 37 MO patients (24 f, 13 m), 60 BD (30 f, 30 m). Levels of adiponectin, PRESENTER: Stacie Schneider (Temple University Hospital) leptin, resistin, TNFα, Il-1α, Il-1β, Il-6, IL-8, MCP-1, PAI-1 were Co-authors: John Daller1, John Meilahn1, Ian Soriano1 measured using the luminex method. Results: Gender-specific differences in adiponectin and leptin levels were measured in the CRC group (median age 64.5 years, BMI 27.2 Surgery, Temple University Hospital, Philadelphia, PA, United kg/m2), the MO group (median age 45 years, BMI 52,0 kg/m2) and States. BD-group (median age 45 years, BMI not ascertained). Adiponectin was significantly decreased in MO patients compared to BD Background: Transplant patients have additional risk factors for (f:p<0.05) and CRC group (f:p<0.01; m:p<0.001) whereas leptin was obesity, primarily due to their underlying disease as well as the use of significantly increased in MO patients (f:p<0.01; m:p<0.001) and immunosuppressive medications. Sleeve gastrectomy has been shown significantly decreased in CRC patients (f:p<0.05) compared to BD to be a safe and effective primary treatment option for weight loss in group. Resistin levels did not show any alterations between the three morbidly obese patients. groups. IL-1α, MCP-1 and PAI-1 were significantly elevated in both, Methods: We present the first laparoscopic sleeve gastrectomy after CRC and MO groups, compared to the BD group. kidney-pancreas transplant in literature as well as an extensive review Conclusion: The chronic inflammation in MO and CRC patients of the experience regarding bariatric surgery in the transplant seems to be the link between obesity and colorectal carcinoma. population. Results: A morbidly obese 36-year-old African American female with a history of kidney-pancreas transplant in 2003 underwent a laparoscopic sleeve gastrectomy in March 2009. The patient had a P-019 Prospective Assessment Of Laparoscopic Adjustable pre-operative BMI of 45 with a history of diabetes and renal failure, Gastric Banding. who presented for evaluation for bariatric surgery. No records regarding her transplant procedure were available. At the time of PRESENTER: Christian Gouillat (Hôpital de la Croix Rousse) surgery, she was found to have a pancreatico-jejunal anastomosis approximately 40 cm past the ligament of Treitz. We proceeded to Co-authors; Angélique Denis2, Perrine Badol-van-straaten2, Marie- perform a standard laparoscopic sleeve gastrectomy. Cécile Blanchet1 Conclusion: Laparoscopic sleeve gastrectomy is a safe, viable and

effective treatment option for post-transplant surgery patients, with 1. service de chirurgie digestive, Hôpital de la Croix Rousse, Lyon, an added benefit of having minimal effect on immunosuppressive France. medication absorption. 2. Pôle IMER , Hospices Civils de Lyon, LYON , France.

Background: Although gastric banding is very popular, there are few prospective data regarding its results. This study aims to prospectively assess the safety and efficiency of the gastric banding. Methods: Between May 2005 and September 2006, 262 consecutive patients operated on using Midband® were included in the study, in 13 centres, and followed during 3 years. Quality of life (QoL) was assessed preoperatively and each 6 months using the SF36 questionnaire. Results: Twenty patients (7.6%) were lost of follow up early after surgery. Vilnius, Lithuania.

Background: to evaluate potential differences between 2 adjustable gastric bands - MiniMizer Extra and SAGB - in terms of weight loss, complications, resolution of comorbidities and improvement of quality of life. Methods: from January 2009 to February 2010, 103 consecutive morbidly obese patients (69 women and 34 men) were included in the randomised prospective study approved by National Bioethics Committee. In 54 patients MiniMizer Extra and in 49 - SAGB was used. The results were evaluated by a multidisciplinary team: cardiologist, gastroenterologist, endocrinologist, surgeon and dietitian. All operations were performed by single surgeon. The comorbidities, time of the operation, intraoperative and early postoperative complications were registered. Results: patients mean age was 45.8 years (range 21-70) and BMI 47.5 (range 35-68.3). 33 patients had type II diabetes, 86 arterial hypertension, 31 sleep apnea, 45 intestinal tract, 5 liver, 28

Post-Operative Upper GI Study gallstones, 5 abdominal wall (hernias), 28 respiratory, 22 heart, 26 genital, 14 urinary tract and 23 thyroid gland diseases, 72 joint and 77 spine pain, 36 varicose leg veins, 5 elephantiasis, 7 psoriasis and 13 other skin diseases, 13 depression and 2 other mental disorders. P-021 “Ganta Stitch”- A Simple Method Of Liver Retraction 4 of the patients had one, 5 – two, 11 – three, 84 - four or more Without Additional Incisions Enabling A True Single Incision comorbidities. Gastric Banding Via Umbilicus Mean operation time in MiniMizer Extra group was 61.5 minutes and in SAGB - 64.8 minutes. PRESENTER: Sashidhar Ganta (Bariatric Surgery, AIBL, There were no intraoperative complications. Three patients had Austin, TX, United States) transitory dysphagia in early postoperative period (1 – 7 days). One MiniMizer Extra band was removed laparoscopically because of penetration in 6 months period. Weight loss results were similar in Background: Single incision laparoscopic surgery (SILS) is emerging both groups (p>0,05) and a handful of surgeons have adopted to perform the gastric Conclusion: Gastric banding can be performed safely with the banding using the SILS approach. The author Dr. Sashi Ganta is one MiniMizer Extra or the SAGB with similar short-term results with of first surgeons in the United states to perform gastric banding using respect to weight loss and complications. the single incision technique via the umbilicus. Majority of the surgeons performing the SILS approach for gastric banding use a Nathanson retractor or another liver retractor and this requires a separate incision in the upper abdomen. Critics state that the procedure is not a true single incision approach because 2 incisions P-023 Severe Reflux After Laparoscopic Sleeve Gastrectomy are being used. Requiring Early Conversion To Gastric Bypass Procedure Methods: The ―Ganta Stitch‖ is a simple method of achieving liver retraction without making additional incisions. A 2-0 ethibond suture placed to repair the crural defect anterior to the esophagus is used to PRESENTER: Lindsey Moore (Wood County Hospital) retract the left lobe of the liver in a V fashion thereby eliminating the 1 Co-authors: Peter F. Lalor nathanson retractor. Results: We report a small series of True SILS gastric banding performed sucessfully with a single 18 mm incision in the umbilicus 1. Center for Weight Loss Surgery, Wood County Hospital, Bowling utilizing the ―Ganta stitch‖ method for liver retraction. This method Green, OH, United States. of liver retraction enables the surgeon to perform a true single incision gastric banding. Background: Laparoscopic sleeve gastrectomy is a legitimate option Conclusion: Our technique describes an easily reproducible, simple, in bariatric surgery, and its complications, long-term efficacy, and cost-effective method of liver retraction during the SILS gastric physiology continue to be investigated. Gastroesophageal reflux banding thereby enabling the surgeon to offer a truly single incision disease and esophageal dysmotility is common in the morbidly obese approach for gastric banding. This technique can easily be adapted to population and may also continue to be a postoperative problem after any SILS procedure that requires liver retraction. laparoscopic sleeve gastrectomy. Methods: Prevention and treatment of significant reflux disease after laparoscopic sleeve gastrectomy may include patient selection, aggressive acid suppression, gastric motility agents, hiatal hernia repair, dilation of strictures, or conversion to gastric bypass. P-022 Laparoscopic Adjustable Gastric Banding: A Prospective Results: We report the case of a patient without preoperative clinical Randomized Study Comparing The Minimizer Extra And The or radiological evidence of reflux or esophageal dysmotility who Sagb: Initial Results. underwent laparoscopic sleeve gastrectomy and then required early conversion to roux-en-y gastric bypass for severe reflux. PRESENTER: Tomas Abaliksta (Vilnius University Medical Conclusion: Pertinent literature review and our own experience with Faculty) laparoscopic sleeve gastrectomy and reflux disease are also discussed. Co-authors: Gintautas Brimas1, Vilma Brimiene1, Kestutis Strupas1

1. Abdominal surgery center, Vilnius University Medical Faculty, and aeroallergen-specific IgE antibodies after gastric bypass surgery. Conclusion: A marked change of IgE reactivity pattern occurred after impairment of gastric digestion due to surgical elimination P-024 One Step Redo Bariatric Surgery underlining the important gate keeping function of gastric digestion against food proteins. PRESENTER: Patrick Chiotasso (Digestive surgery, CHU Purpan, Toulouse, France) This work was supported by OeNB Jubiläumsfond 11375 and grants P21577-B11 and SFB F 1808-B13 of the Austrian Science Funds FWF. Background: Usually, redo bariatric surgery is performed in 2 step in order to avoid an increased risk of postoperative morbidity and particularly the risk of gastric fistulae after laparoscopy. The purpose of the study was to evaluate the risk of postoperative morbidity after P-026 Visceral Adipose Heme Oxygenase-1 Expression Is a one step redo bariatric surgery done by laparotomy. Determined By Hip To Waist Ratio And Linked To Insulin Methods: All consecutive patients having had a redo bariatric surgery Sensitivity between january 2006 and january 2010, were retrospectively reviewed. There were 26 cases. The mean age was 44.2 years (22 - 61). There were 23 females and 3 males. The first bariatric surgery PRESENTER: Soheila Shakeri-Manesch (Medical University of was a band in 22 cases, a vertical banded gastroplasty in 3 cases, a Vienna) sleeve gastrectomy in 1 case. In the second procedure, all the bands 2 2 2 were removed and 11 had a VBG, 14 a gastric bypass, 1 no Co-authors: Maximilian Zeyda , Joakim Huber , Bernhard Ludvik , Gerhard Prager1, Thomas M. Stulnig2 procedure. Results: No patient presented a gastric fistulae during the postoperative period and the late follow-up. There were no other 1. Surgery, Medical University of Vienna, Vienna, Austria. major postoperative complication except an early anastomotic 2. Clinical Division of Endocrinology and Metabolism, Department bleeding gastrojejunal ulcer. of Medicine III , Medical University of Vienna, Vienna, Austria. Conclusion: Doing a redo bariatric surgery through a laparotomy is feasible in a one step procedure without a high risk of gastric fistulae Background: Insulin resistance in visceral obesity is substantially or major postoperative complications. driven by adipose tissue inflammation, in particular macrophages accumulating in obese adipose tissue. On the other hand, adipose tissue macrophages express the hemoglobin scavenger receptor (CD163) and heme oxygenase-1 (HO-1) that together protect from P-025 The Effect Of Surgical Elimination Of The Gastric oxidative stress. Aim of this study was to evaluate the expression of Digestion On Food Protein Sensitization CD163 and HO-1 in visceral (omental) and subcutaneous adipose tissue as well as circulating soluble CD163 concentrations in human PRESENTER: Soheila Shakeri-Leidenmühler (Medical obesity and its association with adipose tissue inflammation, body fat University of Vienna) distribution, and insulin resistance. Methods: Morbidly obese patients (BMI > 40 kg/m2) who underwent Co-authors: Anna Lukschal2, Cornelia Schultz2, Arthur Bohdjalian1, laparoscopic surgery for gastric banding (n=20), matched for age and Felix Langer1, Tudor Birsan1, Susanne C. Diesner3, Elli sex to lean control subjects (BMI < 30 kg/m2; n=20). Greisenegger4, Otto Scheiner2, Tamara Kopp4, Erika Jensen-Jarolim2, Main outcome measures: Eva Untersmayr2, Gerhard Prager1 CD163, HO-1, and CD68 mRNA expression in visceral and subcutaneous adipose tissue; serum concentration of soluble CD163.

Results: CD163 expression was highly upregulated in human adipose 1. Surgery, Medical University of Vienna, Vienna, Austria. tissue and soluble CD163 serum concentration was elevated in obese 2. Pathophysiology, Infectiology and Immunology, Medical vs. lean subjects. HO-1 was upregulated in adipose tissue by obesity University of Vienna, Vienna, Austria. as well and expressed predominantly in macrophages. While CD163 3. Pediatrics and Adolescent Medicine, Medical University of expression strictly correlated with macrophage abundance, HO-1 was Vienna, Vienna, Austria. additionally upregulated within macrophages, and this upregulation 4. Dermatology, Medical University of Vienna, Vienna, Austria. was significantly lower in visceral compared to subcutaneous adipose tissue. Strikingly, relative visceral adipose tissue expression of HO-1 Background: We have previously reported that impairment of gastric negatively correlated with waist to hip ratio and HOMA-IR (both p = digestion due to pH elevation represents a risk factor for food allergy 0.024). induction. Based on these observations we aimed to analyze in a Conclusion: Our data suggest visceral obesity to promote insulin prospective study the effect of elimination of the gastric digestion by resistance by reduced visceral adipose tissue expression of HO-1 surgical interventions on food allergy induction. abrogating its anti-oxidative and anti-inflammatory action. Methods: Eleven patients undergoing Roux-en-Y gastric bypass surgery for morbid obesity, meeting the inclusion criteria, were enrolled in the study and compared to a control patients having P-027 Efficacy Of Bariatric Surgery In The Treatment Of undergone surgery for treatment of an incisional hernia. Before and 1, Obesity-Related Type Ii Diabetes Mellitus – 24 Months Follow 3, 6, 9 and 12 months after the surgical intervention blood was Up collected for analysis of specific IgE antibodies and patients were subjected to skin prick testing with 16 food as well as 18 aeroallergens. PRESENTER: Soheila Shakeri-Manesch (Medical University of Results: The evaluation of skin prick test results revealed an increase Vienna) of positive skin reactivities indicating sensitizations towards the Co-authors: Bernhard Ludvik2, Arthur Bohdjalian1, Felix Langer1, tested food compounds and towards the aeroallergens in 72% of the Karin Schindler2, Johannes Zacherl1, Gerhard Prager1 patients only after surgical elimination of gastric digestion. These results were in line with determined elevated titers of food-specific 1. Surgery, Medical University of Vienna, Vienna, Austria. 2. Clinical Division of Endocrinology and Metabolism, Department PRESENTER: Robert Rutledge (Center for Laparoscopic of Medicine III, Medical University of Vienna, Vienna, Austria. Obesity Surgery, Henderson, NV, United States)

Background: Up to 80% of the diabetes mellitus type 2 population Background: Prediction of expected weight loss following bariatric are overweight. Effective weight control can lead to improvement or surgical procedures can be difficult. Accurate prediction of expected even resolution of diabetes. Bariatric surgery represents a suitable weight loss following bariatric surgery would be valuable to patients, option for sustained weight loss in severely obese-diabetic subjects. physicians and others. A regression model of weight loss as a Conservative treatment results in reduced weight loss for diabetic function of time from surgery and preoperative weight using data patients when compared to a non-diabetic control group. There is from 3,883 Mini-Gastric Bypass patients. little evidence whether this difference also exists after bariatric Methods: A curve fitting program (DataFit) was used to fit functions surgery. to of data on weight loss information on 3,883 MGB patients. Methods: The change in the diabetic status and weight loss in 85 Regression analysis was used to grade the curves fit to the data. (26m/59f, BMI 48.3 kg/m2) morbidly obese diabetic subjects Results: 242 models were generated with R2 values of between 0.60 undergoing bariatric surgery in a single institution was analysed. and 0.87. The equation with the highest R2 was excessively complex. Evidence of stable treatment was required with oral antidiabetic The relatively simple equation a+b*log(x1)+c*x2 where a, b and c agents or insulin. The control group consisted of 85 morbidly obese, are constants, x1 = the number of months following surgery and x2 is non-diabetic patients, matched for age, sex, BMI and type of bariatric the starting weight Fig 1.) The weight loss following MGB varies procedure. directly with the preoperative weight and with the log of the time Results: Mean excess weight loss (EWL) was 38.4% after six, 49.5% following surgery. The R2 for this equation was 0.84. Predicted after 12 and 54.7% after 24 months in the diabetic group. In 76 values for weight loss in a 300 lb patient having the MGB was 25 lbs (60.32%) subjects of 126 diabetes resolved completely and 36 at one month, 60 lbs at 3 months, 82 lbs at 6 months and 155lbs at 5 subjects (28.57%) had significantly improvement of diabetes during years. 24 months. The control group exhibited an average EWL of 41.7% at Conclusion: A significant amount of uncertainty and anxiety can be 6 months, 54.1% at 12 and 58.6% after 24 months. There was no associated with the expected and predicted weight loss following significant difference in weight loss between both groups at 6, 12 and bariatric surgery. A relatively simple model of starting weight and 24 months. log of the time from surgery allow a very accurate prediction Conclusion: Laparoscopic bariatric surgery resulted in significant, (r2=0.84) of weight following MGB alleviating some anxiety and sustained weight loss leading to remission or amelioration of diabetes unreasonable expectations. in almost all patients. Contrary to conservative treatment there was no difference in EWL between the diabetic and non-diabetic group. P-030 Further Study Of Supplemental Dexmedetomidine And Ketamine Opioid Sparing Anesthesia/Analgesia In Mini-Gastric P-028 Mini-Gastric Bypass As A Successful Rescue Of Failed Bypass Laparoscopic Adjustable Gastric Band

PRESENTER: Robert Rutledge (Center for Laparosocpic PRESENTER: Robert Rutledge (Center for Laparosocpic Obesity Surgery, Henderson, NV, United States) Obesity Surgery, Henderson, NV, United States.)

Background: Narcotics, the foundation of pain management in Background: Adjustable gastric banding has been widely used but bariatric surgery, have serious, potentially deadly side effects. increasingly failures of the band have been reported. With large scale dexmedetomidine and ketamine non-narcotic drugs have opioid popularity and a gastric banding failure rate of nearly 40-50% at 5 sparing effects. years, the need for revision surgery is increasing. Methods: This report extends a previous study in Mini-Gastric Laparoscopic mini-gastric bypass (MGB) as a rescue procedure for Bypass MGB patients were treated with either total intravenous failed band patients is an effective technically simple and safe anesthesia (TIVA) with (TKD) or without (TNO) opiod sparing doses procedure that has the advantage of being a single stage procedure, of supplemental ketamine (50-150mg) and dexmedetomidine (100 μg being easily reversible and revisable in a laparoscopic procedure and IV over 10 minutes.) Post-anesthetic recovery analogue pain score does not sacrifice portions of the stomach or implant foreign (APS) and narcotic use (# of doses), post operative nausea and materials. vomiting (PONV) and overall patient satisfaction were compared. Methods: Over 30 months, 1,364 patients underwent MGB. 62 cases Results: Over a 3 year period 1011 patients underwent MGB. The (5%) underwent revision of laparoscopic gastric band (LGB) to MGB mean age 39, 85% female, mean BMI 46, mean operative time 38 as a rescue procedure. min. No patient required reintubation for respiratory depression. TKD All the procedures were laparoscopically performed by the same patients had: a 90% lower mean APS, 85% fewer doses of rescue surgeon at a single institution. narcotics, a higher mean respiratory rate in recovery room (12 vs 9), Results: The LGB patients were 44.5 age, body mass index (39.2 +/- less PONV (10 vs 35%) and higher levels of patient satisfaction 7.2 kg/m(2) excess body weight 53.7 kg. Operative time (59 +/- 15.9 (p<0.05 in all.) minutes short but longer than non-revision MGBs) the morbidity was Conclusion: Morbidly obese patients present a serious anesthetic similar (5.5%) The 1-year percentage of excess weight loss was challenge. Opioid sparing ketamine and dexmedetomidine techniques excellent (68.1% +/- 15%). significantly decreases respiratory depression and PONV caused by Conclusion: LGB is a popular U.S. weight loss procedure with a very narcotics. This decreases the need for narcotics, improves pain score, high expected failure rate. The MGB is a safe, simple and effective decrease PONV and improves overall patient satisfaction. weight loss procedure performed as a rescue after failed laparoscopic band. P-031 Non-Resectional: Mini ("Sleeve") Gastroplasty (Msg)

P-029 Accurate Prediction Of Weight Loss Following The Mini- Gastric Bypass: Multivariate Regression Modeling With PRESENTER: Robert Rutledge (Center for Laparosocpic Preoperative Weight And Time From Surgery Obesity Surgery, Henderson, NV, United States) Blood Loss Low Low <50 ml Moderate Background: The sleeve gastrectomy (SG) has gained popularity Op Time Short Short (38 Min) Moderate because of several advantages. One concern is that the SG surgery is irreversible. Hospital Stay Short Short (Median 1 day) Moderate Methods: The Mini-Gastric Bypass has used a gastric sleeve 30 d Complications 7% 8% 23% reconstruction since 1997. In selected Mini-Gastric Bypass patients the bypass portion was omitted and only a Mini ("Sleeve") Stricture 1% 1% 14% Gastroplasty (MSG) was chosen for patients, 1: were morbidly obese %EWL 45% 81% 68% but could not have a bypass and 2: for those that needed lesser weight loss. The MSG consists of a complete division of the lesser curve Failure Rate 17% 1% 0% from the body of the stomach to the antrum. The gastric tube is then Hospital Costs $11,000 $6,500 $12,000 reattached to the distal stomach with a 1 cm diameter anastomosis. Results: The MSG was chosen for 55 patients who had morbid obesity (MO) and an inability to perform a bypass and 352 patients underwent MSG because of less severe obesity (LSO). Mean P-033 Association Of Bypass Limb Length And One Year Weight preoperative BMI in MO patients was 46 kg/m2, and mean Excess Loss In 3,883 Mini-Gastric Bypass Patients Body Weight (EBW) was 65 kg. The mean BMI in LSO patients was 36 and the mean EBW was 33 kg. There was no mortality. Mean PRESENTER: Robert Rutledge (Center for Laparosocpic weight loss was 31 kg (±10 kg), equivalent to 48% of EBW in MO Obesity Surgery, Henderson, NV, United States) patients. Mean weight loss in LSO patients was 29 kg (±12 kg), equivalent to 87% of EBW. Conclusion: The MSG results are similar to Band and Sleeve Background: Common sense suggests that a longer bypass should increase weight loss after gastric bypass. Although several studies Gastrectomy reports. It is simple and successful LSO patients. In MO have concluded that longer bypasses do not increase weight loss, the patients the absolute weight loss remains the same, although it can be useful in staged procedures and when a bypass cannot be performed. sample sizes were quite small. This study analyzed the association of The Mini-Sleeve Gastroplasty avoids the foreign body of the Lap limb length and weight loss in a large series of Mini-Gastric Bypass patients. band and unlike the Sleeve Gastrectomy is easily reversible.

Methods: 3,883 patients underwent Mini-Gastric Bypass and completed 1 year of follow up. Bypass limb length was modified P-032 Comparison Of The Mini-Gastric Bypass With The based on starting weight. Reported Results Of A Prospective Randomized Trial Of Rny Results: Weight loss following MGB surgery followed a logarithmic Gastric Bypass Versus Adjustable Gastric Band decline though the end of the first year and then leveled off. Bypass limb length varied from .5 - 3 meters. Weight loss increased PRESENTER: Robert Rutledge (Center for Laparosocpic as bypass limb length increased (fig 1., p<0.0001.) Obesity Surgery, Henderson, NV, United States) The preop weight was also strongly related to weight loss. A multivariate regression model using bypass length and preop weight Background: In a recent study by Nguyen et.al. the results of a improved the predictive value of the model, Wt Loss = 13.04 + randomized trial of band vs RNY bypass concluded that "both are Bypass*6.98 + PreOP Wt*0.25 (Fig. 2, p<0.0001, r2= 0.38.) The safe and effective approaches for the treatment of morbid obesity." model explains almost 40% of the variance in the weight loss and However each was found to have advantages and disadvantages. The predicts a mean increase of 6.9 kgs of weight loss for every purpose of this study was to compare the outcomes of 3,800 Mini- additional foot of bowel bypassed. Gastric Bypass (MGB) patients with the reported results of the trial Conclusion: This is the largest reported study of bypass length and by Nguyen et.al. weight loss after gastric bypass. Prior negative studies with small Methods: Data were collected prospectively in database system sample sizes may have suffered from a Type II error. The study tracking outcomes on all operated patients. 3,800 patients had follow demonstrates that both preop weight and limb length are significantly up data for analysis. Outcomes were compared to data reported by associated with weight loss and that every additional foot of bowel Nguyen et.al. bypassed is associated with a mean increase of 6.9 kgs to the Results: The table shows the comparison: expected one year weight loss. Conclusion: While the safety and efficacy of the band and the RNY are known; both the RNY and the band fall far short of being an ideal surgery for obesity. The MGB has many of the advantages of the band (short, simple, low risk, reversible and revisable) and many of P-034 Do White Cell Count And C–Reactive Protein the advantages of the RNY Bypass (much more effective and durable Concentrations Predict Anastomotics Leaks In Patients over the long term). These data suggest that the MGB should be Undergoing Roux-en-Y Gastric Bypass? studied in comparison to the band and RNY bypass as the operation of choice for obesity. PRESENTER: Dugal Heath (Whittington Hospital)

Nguyen N et.al.. Ann Surg. 2009 Aug 27., A Prospective Co-authors: Louisa Obuna1, Kirsten McDougall1, Lucy Jones1, Sufi Randomized Trial of Laparoscopic Gastric Bypass Versus Pratik1 Laparoscopic Adjustable Gastric Banding 1. Bariatric surgery, Whittington Hospital, London, uk, United Kingdom. Band v. MGB v. RNY

Band MGB RNY Background: Anastomotic leakage is reported to occur with a Mean Age 45 47 41 frequency of 1 in 20 Roux–en–Y gastric bypasses (RYGB). Features Mean BMI 45 47 48 suggestive of leakage include abdominal pain, pyrexia, increased respiratory rate, tachycardia and other features of sepsis. However, in some patients anastomotic leakage can be extremely difficult to PRESENTER: Kirsten McDougall (Whittington Hospital) detect and may result in a delay in diagnosis. In this study we examine whether changes in the white cell count (WCC) and c– Co-authors: Lucy Jones1, Sufi Pratik1, Dugal I. Heath1 reactive protein (CRP) can be employed to help in predicting an anastomotic leak. 1. Bariatric surgery, Whittington Hospital, London, uk, United Methods: We identified patients undergoing laparoscopic RYGB Kingdom. over a six month period from an in house database. WCC and CRP values were extracted from the pathology reporting system for the Background: Patients gain information regarding bariatric procedures first three days post surgery. from many sources including friends, media and the internet. Whilst Results: 61 patients were operated during the study period with two many of the sources cannot be considered objective they do influence developing anastomotic leaks. Differences in median WCC between a patient‘s choice of procedure. In this study we examine how those with and without anastomotic leak on days 1, 2, and 3 were as patients‘ initial choice of procedure is influenced by attending a follows 12.3 and 13.3; 11.5 and 13.2; 10.71 and 2.8 respectively. group education. Values for CRP were 14.31 and 6; 49.66 and 64.5; 135.6 and 356. Methods: All patients referred for bariatric surgery attended a group Differences in WCC and CRP on day 3 were significantly (p = education session at the beginning and end of which they were asked 0.025). to fill out a questionnaire which included information regarding their Conclusion: Whilst WCC and CRP concentrations are unlikely to be preferred surgical procedure. of value in detecting a leak when used alone, a suppressed WCC with Results: At the beginning of the educational session, 159 (40%) of an elevated CRP on day 3 is associated with an anastomotic leak. 403 patients indicated they preferred gastric banding, 138 (34%) Roux-en-Y gastric bypass, 101 (25%) did not know or expressed uncertainty, three (<1%) wanted a sleeve gastrectomy and 2 (<1%) an intragastric balloon. At the end of the educational session 101 (25%) P-035 A Comparison Of Resource Utilization, Costs, Charges patients expressed a preference for gastric banding, 218 (45%) for And Reimbursement For The Mini-Gastric Bypass, Drg 288 “Or RYGB, 80 (20%) did not know or expressed uncertainty, 4 (<1%) Procedures For Obesity” And Drg 494 “Laparoscopic preferred a sleeve gastrectomy and none intragastric balloon. The Cholecystectomy W/O Cde W/O CC number of patients who maintained their original choice were 73 (46%), 119 (86%), 28 (28%), 1 (33%) and 0 (0%) respectively. Conclusion: A group education session held prior to being seen in PRESENTER: Robert Rutledge (Center for Laparoscopic clinic provides patients with information that significantly influences Obesity, Hendersonville, NV, United States) and alters their choice of surgical procedure.

Background: The Mini-Gastric Bypass (MGB) has numerous reported advantages. The purpose of this study was to use data from P-037 Subjective vs. Objective Resolution Of Diabetes Mellitus national healthcare databases to compare the outcomes of the MGB Following Mini-Gastric Bypass: Patients' Subjective Assessment to DRG 288 ―Surgery Procedures for Obesity‖ and DRG 494 Of Resolution Lags 1-3 Years Behind Objective Resolution ―Laparoscopic cholecystectomy without common duct exploration without complications, comorbidities‖ (LC.) PRESENTER: Robert Rutledge (Center for Laparosocpic Methods: Data were obtained on the MGB from the continuously Obesity Surgery, Henderson, NV, United States) updated database of the Centers for Laparoscopic Obesity Surgery (CLOS). National data on DRG 288 and 494 were obtained from Solucient a leading source of health care information. The nation's Background: A recent controlled prospective randomized trial largest health care database comprised of more than 22.6 million concluded that the Mini-Gastric Bypass was roughly twice as discharges per year from 2,900 hospitals - representing 77.5 percent effective as the Sleeve Gastrectomy in the resolution of Type 2 of all discharges. Diabetes Mellitus (DM), resolution rate MGB 90% vs SG 50%. Results: There were 78,796, 164,696 and 2,833 DRG288, 494 and Objective resolution of DM can be defined as no longer requiring MGB patients for study respectively. Hospital charges were 33,108, oral medications to treat hyperglycemia, but patients may still feel 12,211 and 27,595, costs 11,419, 4,768 $5,062+$2,400 disposables, subjectively that they should be labeled as "Diabetics." Reimbursement was 11,170, 4,263 and 8,000 respectively for DRG The present study was designed to assess the relation between the 288, 494 and MGB. The average length of stay was 4.98, 2.5 and 1.1 objective and the subjective resolution of DM following Mini-Gastric days. Bypass (MGB). Outliers occurred in 4.90%, 0.2% and 0.5% of patients, complications Methods: Pre- and postoperative demographics, DM in patients were recorded in 8.66%, 0.15% and 5.01% and Hospital Mortality undergoing MGB from 2007 - 2009. Rate was 0.31%, 0.01%, 0.0% for DRG 288, 494 and MGB all Results: 678 patients underwent MGB (22%) had DM. There were respectively. 85% females with a mean preoperative age of 39 years (range, 12-81 Conclusion: Comparison of MGB to DRG 288 Weight Loss Surgery years). After surgery, weight and body mass index decreased from Nationally shows MGB patients have lower charges, and cost with 295 lbs and 49.1 kg/m2 to 171 lbs and 28.5 kg/m2 for a mean weight better reimbursement. The average length of stay is shorter for MGB loss of 124 lbs, an ideal body weight of 140 lbs and mean excess than for DRG 288 or 494. Outliers were higher for DRG 288 and the weight loss of 81%. The mean operative time was 37 minutes + 10 complication rate and mortality rate of MGB were lower than for and the median hospital stay was 1 day. By objective measure DM DRG 288. Excluding the expense of disposable surgical equipment resolved in 93% of patients 1, 2 and 3 years following surgery. the MGB has transformed weight loss surgery to a procedure with the The subjective measure lagged significantly behind the objective resource utilization and outcomes comparable to an uncomplicated measure ("Taking oral Medications?"), The rate of patients still laparoscopic cholecystectomy, DRG 494 labeling themselves as diabetics was 26%, 16.7% and 7.3%, 1, 2 and 3 years following surgery. Conclusion: This study again confirms that the Mini-Gastric Bypass P-036 Study Of The Influence Of Patient Education On Choice is an excellent therapeutic tool leading to resolution of DM in 93% of Of Bariatric Procedure. patients. As measured by the need for oral anti-diabetic medications 93% of MGB patients resolve their diabetes 1-3 years following surgery. Patients subjective self labeling takes longer to change lagging up to three years behind objective resolution. technique (1.76%). The non-fixation technique, reduces the frequency of slippage in total (1,49%), in comparison with fixation (8,51%), whether using the peri-gastric technique (14,69%), or the pars flacida technique (2,16%). There is no significant difference using SAGBor MidBand, although the number of first (66), is limited P-038 Revisional Operations After Failed Bariatric Surgery to give final results. All these conclusions demand longer time ratification in a border of perspective studies.

PRESENTER: Philipp Beckerhinn (Landesklinikum Hollabrunn)

Co-authors: Stefan Schoeppl1, Claudia Fenz1, Franz Hoffer1

1. Surgery, Landesklinikum Hollabrunn, Hollabrunn, Austria. 1994 - 2001 Peri-gastric, LapBand with fixation 143 cases

2005 - 2006 Pars flacida, SAGB with fixation 139 cases Background: Laparoscopic gastric banding (AGB) is still the most frequent bariatric procedure in Europe and is becoming more and 2006 – 2007 Pars flacida SAGB non-fixation 66 cases more popular worldwide. Long-term complications (band slippage, 2007 – 2008 Pars flacida MidBand non-fixation 135 cases band migration, pouch or oesophageal dilatation) as well as failure of 1994 – 2008 Total 483 cases weight loss require revisional surgery. Weight regain following stapleline disrupture after open vertical banded gastroplasty (VBG) results in reoperation. The purpose of the study was to measure outcomes after reoperations. P-040 Six years experience with adjustable gastric band. Analysis Methods: Demographic and medical data of all patients were of 1582 cases – 41 tonnes weight loss prospectively monitored. Surgical results, changes in weight, comorbidities and quality of life using the Bariatric Analysis and PRESENTER: Nicholas Sikas (Interbalkan Medical Center, Reporting Outcome System (BAROS) were analyzed. Thessaloniki, Greece) Results: Between June 2004 and February 2010 94 women and 13 men underwent revisional bariatric procedures (83 of them were done laparoscopically). The mean age was 41 (range: 18 - 64), the mean Background: The aim of this study was to determine the long-term BMI was 42 kg/m2 (range: 19 -68) at the time of reintervention. The results of LAGB in a series of 1582 patients with high follow-up rate, initial operation was AGB in 84 patients, VBG in 14, Sleeve all operated by one surgeon. Gastrectomy in 7, RYGBP in 1 and a gastric pacemaker in 1 patient. Methods: Between April 2004 and February 2010, 1582 patients have Conversion to open surgery was necessary in 2 cases. Major undergone LAGB in a single center using the Helioscopie band (gastropleural fistula, intestinal lesion, bleeding, hernia) and minor (Heliogast® HAGE). The pars-flaccida technique was used and close complications (wound infections) required reoperation in 16 patients. follow-up was achieved in 96.6% of patients. Mean follow-up was There was no mortality in this series. 37±13 months, range 12-70. Complication rate and weight loss have Conclusion: Reoperations after failed bariatric procedures can be been prospectively recorded. performed safely, but the rate of complications is higher in Results: The mean age of patients was 37±11 years (range 15-70), comparison to primary procedures. These operations are effective mean weight 130±28 kgs (range 87-265) and mean BMI 45± 7(range regarding weight loss, reduction of comorbidities and improvement 30-75). The mean hospital stay was 24 hrs, 2.7% of patients were of life quality. discharged home the same day. There was 1 mortality (0.06%) from massive pulmonary embolism 22 days postoperatively. Early complications were found in 4 patients (2 cases of bleeding, 2 cases P-039 Is The Fixation Of The Gastric Band Useful? of stoma obstruction). All 4 cases required reoperation. Late complications comprised slippage in 64 patients (4.3%), erosion PRESENTER: Nikolaos Koutsogoulas (Neo Athinaion MD 15(1%) and band infection in 3 patients (0.18%). Mean excess weight Hospital) loss was 49%, 60%, 65%, 65%, 68% and 68% at 1, 2, 3, 4, 5 and 6 years respectively. Better results were found in patients with BMI 30- 39. Resolution of comorbidities was seen in the majority of patients. Co-authors: Odysseas Boudouris1, Youla Boura2, In patients with a complete 2-year follow-up, failure (<25% EWL, lost to follow-up, band explanted) rate was 9.5%. Two years post- operatively, 77 patients (8%) underwent plastic surgery (mostly 1. Bariatric surgery, Neo Athinaion MD Hospital, Athens, Greece. abdominoplasty). Sixty-eight pregnancies have been reported. 2. Bariatric surgery, Obesity Medical unit (IMoP), Athens, Greece. Conclusion: LAGB is a safe and reversible procedure, offering

excellent long-term results for the treatment of severe obesity. Background: The non-fixation of the gastric band makes operations simpler and mostly leaves the field free for a possible re-operation. Our purpose is to evaluate the effect of fixation of the band in the P-041 Laparoscopic Bariatric Surgery After Previous Anti- frequency of slippage. Reflux Procedure – Should The Fundal Wrap Be Taken Down? Methods: Four series of gastric band operations were performed from the same surgical team. Minimal follow-up: 10 months and average 2 PRESENTER: Kesava Reddy Mannur (Homerton University years and 8 months Hospital) Results: The treatment of slippage was the removal of the band in 21 cases, replacement in 3, conversion to sleeve in 2, and to by-pass in Co-authors: Harun Thomas1, Kalpana Devalia1, Sara Ajaz1, 1. The χ2 test shows a statically significant difference Conclusion: Although this study is not a randomized one but retrospective, results clearly establish that the peri-gastric technique 1. Bariatric Surgery, Homerton University Hospital, London, United is linked with a higher slippage rate (14,69%) than pars flacida Kingdom. clinical suspicion of a leak early re-laparoscopy should be performed. Background: Morbidly obese patients are at an increased risk of gastro-oesophageal reflux disease and some of them undergo fundoplication. They may later require Roux-en-Y gastric bypass P-043 Laparoscopic Gastric By-Pass: Preliminary Results Of A (RYGB) or sleeve gastrectomy (SG) as weight loss measure. Personal 7.5 Year Series Methods: Retrospective review of our prospective bariatric database from January 2004 to January 2010 was undertaken to identify these PRESENTER: Mario Neves (Hospital CUF Infante Santo, patients. 953 cases were reviewed which identified 4 patients who Lisbon, Portugal) underwent RYGB or SG after fundoplication. We looked at the complications and the reason behind this. Literature review using Background: I treated 337 patients with Morbid Obesity.My medline was performed. operation of choice is the Laparoscopic Gastric By-Pass which was Results: 2 patients had RYGB and 2 had SG. One complication was performed in 223 of my patients (66.2%). noted in each group. Methods: I have followed the current standard for operative selection Patient 1- We initially attempted to staple divide the stomach in SG of patients with a body mass index (BMI) over 40 kg/m2 or over 35 with the fundoplication intact. This resulted in opening up of the kg/m2 in the presence of significant co-morbidities. stomach at the staple line. The defect was closed with suture and SG Results: In the first 100 cases, as major early complications there was completed with an uncomplicated recovery. have been 4 anastomotic leaks (1.79%) and in the latter cases there Patient 2- We took down the fundoplication partially and performed have been 1 (0.45%).There has been 1 case of mortality (0.49%).The the RYGB. On the first postoperative day she complained of severe mean % of Excess Body Weight Loss (%EBWL) at 7 years past the abdominal pain. Laparoscopy was performed and a perforation was procedure is 77%. identified in the staple line of fundus of the remnant stomach. Fundus Conclusion: The operative complications diminish with the increased was stapled and removed from remnant stomach. She made an experience. The mortality and the morbidity is low and the co- uneventful recovery. morbidities are greatly reduced if not totally cured. Patient 3 and 4- We took down the fundoplication completely and proceeded with SG or RYGB. Both patients had an uncomplicated recovery Conclusion: Bariatric surgery following fundoplication is feasible but Table 1 – Personal experience in Bariatric Surgery: 337 patients in attendant with increased complications. The fundoplication has to be 7.5 years meticulously taken down before the bariatric surgery is performed. Literature supports this observation. Vertical banding gastroplasty - Mason 1 0.3% Open Duodenal Switch 32 9.5% Laparoscopic Sleeve Gastrectomy 28 8.3% P-042 Imaging In Diagnosing Leak After Laparoscopic Bariatric Surgery- Is It Helpful? Laparoscopic Gastric By-Pass 223 66.2% LaparoscopicAdjustable Gastric Band 56 16.6% PRESENTER: Kesava Reddy Mannur (Homerton University Hospital) Table 6 – Early surgical complications (first 30 days) Co-authors: Harun Thomas1, Samrat Mukherjee1, Kalpana Devalia1, Yashwant Koak1, Luigi Angelini1, Kamini Patel1 First 100 First 100 101-223 101-223 1. Bariatric Surgery, Homerton University Hospital, London, United Type cases cases cases cases (number) (percentage) (number) (percentage) Kingdom. Gastroenterostomy 4 2.3% 0 0% Background: Clinical features of leak after laparoscopic bariatric leaks procedures are subtle. The role of computerised tomography (CT) Enteroenterostomy 0 0% 1 0.49% scan and contrast swallow in the diagnosis of leak is controversial. In leak this study we have analysed our experience with imaging in the Intestinal diagnosis of these leaks. 1 0.49% 0 0% Methods: Retrospective review of our prospectively maintained Obstruction bariatric database from January 2004 to January 2010. The clinical Intraabdominal 0 0% 1 0.49% records of all patients with a leak were analysed by a single reviewer. infected hematoma The diagnosis of leak was confirmed by the direct visualisation of the Gastric leak in patients who were re-operated or the persistent drainage of 0 0% 1 0.49% haemorrhage gastric contents through the drain in patients who were managed Acute perforated conservatively. The surgical procedure, post-operative clinical 0 0% 1 0.49% features, imaging findings, and management were recorded. All the ulcer radiological images were reviewed by a specialist gastrointestinal Gastroenterostomy 2 0.90% 0 0% radiologist. stenosis Results: 953 patients underwent bariatric procedures during the time period. There were 12 leaks during the time period (8 primary and 4 Minor infections 9 4.04% 0 0% revisional). 5 of the patients with leak had a CT scan and 3 had a Mortality* 0 0% 1 0.49% contrast swallow. 2 of the CT scans and all 3 of the contrast swallows * death occured at the 52th day of the postoperative period demonstrated the leak. 4 patients underwent re-laparoscopy without imaging after clinical suspicion of the leak. Negative imaging delayed the re-intervention in 2 patients. P-044 Periodical Emptying Of The Gastric Band System Conclusion: CT scan in the early post-operative period after a Reduces Band Migration bariatric procedure is not accurate in diagnosing a leak. In case of PRESENTER: Branko Breznikar (Splosna Bolnisnica Celje, Kamil Safiejko1, Jacek Dadan1 Kotlje, Slovenia) 1. 1st Department of General and Endocrinological Surgery, Medical Background: Gastric banding is a less demanding bariatric procedure University in Bialystok, Bialystok, Poland. with a low complication rate. Migration , slippage and dilatation of the pouch still occur in too high a number of patients. We believe that periodically emptying the gastric band system improves results and Background: The aim of the study is evaluation of results of reduces the complications without significantly altering the weight treatment morbidly obese patients with methods: Laparoscopic reduction. Adjustable Gastric Banding – LAGB, Laparoscopic Roux-en-Y Methods: Presented are the results of our experience in bariatric Gastric Bypass – LRYGB and Laparoscopic Sleeve Gastrectomy – surgery over the last 5 years. There were 250 gastric bandings among LSG. other bariatric procedures. We secure the band in place with 1-3 Methods: In 1st Department of General and Endocrinological Surgery stitches of the fundus to the left crus and/or the gastric pouch. We Medical University of Bialystok from 2005 to 2009 the laparoscopic monitor the patients almost monthly (individually and in the support bariatric procedures were performed in 113 patients (64 females and group) during the first year. We empty the system for one month each 49 males) at age from 18 to 64 (mean – 44.5) and BMI 41-57 (mean- year. 45.5). Results: Reduction of the body weight, band removal, and re-do Results: The hypertension was diagnosed in 19 patients, coronary operations are comparable to the literature. However, we have only disease – 9, diabetes – 15 and two patients underwent cardiac infarct seen one migration and two slippages so far, which is significantly in anamnesis. LAGB was performed in 71 patients (45 females and less than what the literature reports. 26 males) with BMI 41-49 in 4 patients the main procedure was Conclusion: We believe that in addition to good and frequent connected with cholecystectomy. LRYGB was performed in 14 monitoring of the patients, emptying the system periodically reduces patients (8 females, 6 males) with BMI 42-53 and in two patients the number of migrations, slippages, and dilatations of the pouch. cholecystectomy was performed. LSG was performed in 28 patients (11 females, 17 males) with BMI 45-57. Complications after LAGB were: thrombophlebitis, suppuration of wound in the trocar place, P-045 Laparoscopic Gastric By-Pass With Fundectomy And severe pneumonia with pleural abscess and migration of band with Stomach Ivastigation. Technique And 6-Year Follow-Up. obstruction symptoms. Patients were discharged 2 days after LAGB, 4 days after LRYGB and 2 or 3 days after LSG. Conclusion: In our opinion mini - invasive bariatric procedures are PRESENTER: Giovanni Lesti (General Surgery , Hospital Villa the most efficient methods in morbid obesity therapy. The number of Pini, Chieti, Italy) serious complications is low and its risk is highest after LAGB. Highly skilled and experienced surgical team should perform laparoscopic bariatric procedures. Background: we have developed a laparoscopic technique wich allows to performe a laparoscopic Roux and Y gastric by-pass with removal of the fundus (fundectomy) and the possibility to investigate P-047 Resolution Of Type 2 Diabetes (T2dm) Is Regularly and to treat the diseas of the stomach, duodenum and biliary tract Observed Even Outside Major Centers (laparoscopic RYGBPfse). The technique and the results are reported Methods: This procedure is done with 3 trocars 10-12 mm and 2 trocars 5 mm. The gastrocolic ligament is opened at Bouchet area and PRESENTER: Rainer Brydniak (Schwarzwald-Baar-Klinikum) is sectioned towards the His angle. 48 F. bougie is introduced in the Co-authors: Silke Mueller1, Norbert S. Runkel1 stomach, linear stapler from- Bouchet area to the lesser curvature 7 cm from the cardias. Three firing of the stapler parallel to the bougie is applied to make the pouch as narrow as possible. The 1. General Surgery, Schwarzwald-Baar-Klinikum, VS-Villingen, jejunum(50cm), is pulled cephalod towards the gastric pouch in Germany. antecolic position. The gastro-jejunum anastomosis is made side to side.. The bending is placed 7 cm from the cardias to close the end of Background: A number of clinical series from major centers have the pouch and leaving a narrow hole between the pouch and the proven that bariatric surgery is an efficient procedure for controlling antrum. The jejunum-ileum anastomosis is made 120-150 cm from T2DM in morbidly obese patients. It is unknown whether these the pouch results can be reproduced outside major centers, too. This study Results: over 6 years follow-up 168 patients underwent these type of aimed to evaluate the results in the first one hundred cases of our operation with the described method. The mean operative time, the small bariatric program. intraoperative complications, the mean post-operative stay, the late Methods: Our bariatric program started in 2007. Clinical data of complication, the average weight loss and the BMI loss didn‘t bariatric patients were collected online and reviewed retrospectively. showed any difference with the classic laparoscopic RYGBP All patients had a body mass index (BMI) of more than 40. Conclusion: the LRYGBPfse presents the same results in average Laparoscopic gastric banding (LGB) was the procedure of choice at weight loss and BMI loss of the classic LRYGBP but allows to the beginning but was replaced by laparoscopic Roux-Y gastric investigate the dysfunctional stomach and decrease the production of bypass (LRYGB) in 2008. paroscopic sleeve gastrectomy (LSG) was ghrelin sintetized and increase the response of the GLP 1 and PYY second-line therapy. Results: 28 patients (mean BMI 47) underwent LGB, 55 patients (mean BMI 57) had LRYGB and 17 patients (mean BMI 50) had P-046 Our Experience In Laparoscopic Bariatric Procedures LSG. 32 Patients were diabetic and on insulin replacement (IT; n=12) or on oral medication (NIT; n=20). Complete/partial remission was observed in 26/6 patients within 6 months of surgery. The rate of PRESENTER: Hady Razak Hady (Medical University in complete remission was 7/10 LGB, 13/14 LRYGB and 6/8 LSG. Bialystok) Remission was observed immediately after surgery in 2/10 LGB, 9/14 LRYGB and 5/8 LSG. Excessive weight loss (EWL) greater Co-authors: Robert Zbucki1, Pawel Iwacewicz1, Pawel Golaszewski1, than 35% resulted in a higher rate of complete remission (70% vs. 54%). Diabetes resolved in 23/27 cases with a duration of T2DM less Michael Darby1, Justin Morgan1, Sally Norton1 than 10 years and in only 1/5 cases with a duration longer than 10 years. 1. Institute of Bariatric Surgery, Southmead Hospital, Bristol, United Conclusion: The rate of remission appears to depend on duration and Kingdom. severity of T2DM. Resolution appears to correlate with weight loss after LGB but started immediately after surgery in both, RYGB and LSG. The control of T2DM in morbidly obese patients by bariatric Background: Laparoscopic adjustable gastric banding is associated surgery is regularly observed even outside major centers. with a small but significant risk of oesophageal dilatation and gastro- oesophageal reflux disease. Pre-existing or acquired abnormalities in oesophageal function put patients at increased risk from such complications. Type II diabetes is associated with oesophageal dysmotility due to autonomic neuropathy and is more prevalent in patients with a diabetic history of 10 years or more. P-048 Adjustable Intragastric Balloon (IGB) To Treat Obesity: A The aim of this study was to investigate the effect of gastric banding Pilot Study on the development of oesophageal dysmotility in diabetic and non- diabetic patients. PRESENTER: Evzen Machytka (University Hospital Ostrava) Methods: 58 patients (BMI 51.1, 39.3-76.9) including 21 diabetics and 37 non-diabetics were studied. All diabetics had pre-operative 2 3 Co-authors: Elisabeth Mathus-Vliegen , Steven R. Peikin , Scott manometry assessed by an independent physiologist. Patients in both 4 1 5 6 Shikora , Pavel Klvana , Asher Kornbluth , Christopher J. Gostout , groups had upper GI contrast studies on day one and one year post- 7 Jeffrey Brooks operatively, which were assessed by a specialist bariatric radiologist blinded to outcomes. Additional data was collated from patient 1. Gastroenterology, University Hospital Ostrava, Ostrava, Czech records. Republic. Results: There was no significant difference between diabetics and 2. Gastroenterology, Academic Medical Centre, University of non-diabetics in terms of mean excess body weight loss (EBWL) at Amsterdam, Amsterdam, Netherlands. one year (29.8% vs. 28.1%). One, asymptomatic, non-diabetic patient 3. Gastroenterology, University of medicine and Dentistry, Camden, had radiological evidence of abnormal motility at one year (EBWL = NJ, United States. 40.2%). One patient in each group had abnormal pre-operative 4. Surgery and Bariatric surgery, Tufts Medical center, Boston, MA, manometry. The diabetic patient developed oesophageal dilatation at United States. four months requiring band deflation (EBWL = 30.4%). 5. Clinical Medicine, Mt. Sinai Hospital, New York, NY, United Conclusion: In this group of patients there was no apparent difference States. in weight loss or oesophageal motility between diabetics and non- 6. Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN, diabetics at one year following gastric-banding. This data precedes a United States. prospective trial using oesophageal manometry to quantify 7. Spatz FGIA, Inc, Jericho, NY, United States. oesophageal motility after gastric banding in diabetic patients.

Background: Assess feasibility, outcomes, and safety of an adjustable IGB post implantation with a migration-preventing non-crushable P-050 Incidence And Management Of Fistulas After Performing anchor. 1000 Roux-en-Y Gastric Bypass Methods: The SpatzTM Adjustable Balloon is mounted on a curled non-crushable catheter that straightens over a guidewire, and passed PRESENTER: Renato Souza da Silva (Treatment Center for transorally, under conscious sedation. Post-implantation, an Morbid Obesity (CITOM) extractable inflation tube housed in the catheter can be snared 2 endoscopically and pulled outside the mouth for volume adjustments Co-authors: Ana Paula Carvalho da Silva , Renata Carvalho da 2 2 . Nine patients (7 female, 2 male); mean BMI 39,0; and mean Silva , Mário Reginato Bettinelli wt.116,5kg were implanted with balloon volumes of 350 to 600cc of saline 1. Treatment Center for Morbid Obesity (CITOM), Porto Alegre - Results: Mean wt. loss was 8,2 kg at 4 weeks; 9,1kg at 6 weeks; 16,6 RS, Brazil. kg at 12 weeks, and 21,2 kg at 18 weeks. Varying degrees of nausea, 2. Universidade Luterana do Brasil (ULBRA), Porto Alegre, Brazil. vomiting or abdominal pain occurred for up to 5 days without need for IGB removal. One patient with symptomatic, non-ulcerating Background: Fistula is among the most frequent complications of gastritis at implantation had IGB removal at day 40 for persistent Roux-en-Y Gastric Bypass (BGYR) and it is cause for great concern symptomatic gastritis. One balloon volume adjustment (125 cc) among experts. It can occur in two ways: with leakage into the performed at 16 weeks for regained appetite, restored appetite peritoneal cavity or drainage outside. These forms have different suppression with loss of an additional 2 kg over the next 7 days. prognoses and management systems, making essential this Conclusion: This adjustable IGB was well tolerated, with mean wt differentiation. The aim of this study is to investigate the incidence of loss of 21,2kg at 18 weeks. IGB volume adjustment successfully these complications and their management. restored appetite suppression and wt loss. Continued weight loss and Methods: This study was designed in historical cohort study with adjustability over longer implantation periods needs to be determined retrospective data of the first 1000 patients treated by the same in larger controlled studies. surgeon of CITOM. Results: A total of 1000 procedures were performed, 467 by laparoscopic surgery and 533 by open surgery. The incidence of P-049 Mmotility And Weight Loss After Gastric Banding Is fistula was 2.20%, 1.00% of these had leakage into the peritoneal Comparible Between Diabetics And Thier Non-Diabetic cavity and 1.20% had drainage to the external environment. The first Counterparts At One Year ones required surgical treatment, with an average of two reinterventions for resolution of the cases. And the second ones PRESENTER: Richard Egan (Southmead Hospital) submitted to non-operative treatment and had their resolution in an average of 21 days of hospitalization. There was only one case of Co-authors: Simon M. Higgs1, Karen Mason1, Hayley E. Meredith1, death related to this complication, which was a fistula with leakage into the abdominal cavity that didn‘t have a response to surgical intervention. Conclusion: Fistulas are frequent complications in BGYR and its management and prognosis are directly related to the pathway, into the abdominal cavity or outside. Fistulas with leakage into the abdominal cavity are more severe complications and require surgical treatment. On the other hand, fistula with drainage to the external environment can be fixed only with conservative non-operative treatment. Although fistulas are severe complications, their mortality rate can be considered as low.

P-051 How We Do Robotically Assisted Laparoscopic Biliopancreatic Diversion With Duodenal Switch. Emerging Technique And Review Of The Literature P-052 Casereport: An Inadvertent Mistake In Jejunojejunostomy PRESENTER: Iswanto Sucandy (Abington Memorial Hospital) In Roux-En-Y Gastric Bypass For Morbid Obesity

Co-authors: Gintaras Antanavicius2 PRESENTER: Alireza Khalaj (Iran University Of Medical Sciences) 1. General Surgery, Abington Memorial Hospital, Philadelphia, PA, United States. Co-authors: Zohreh Zarghamifard1, Hossein Saeidi Motahar1, 2. Institute for Metabolic and Bariatric Surgery, Abington Memorial Masoud Amini1, Abdolreza Pazouki1, Parvin Shapoori1, Anahita Hospital, Philadelphia, PA, United States. Aslani1

Background: Numerous techniques of Biliopancreatic Diversion with 1. MIS, iran university of medical sciences, tehran, tehran, Iran, Duodenal Switch (BPD/DS) operation have been described – open, Islamic Republic of. laparoscopic and hybrid. We describe our technique of robotically assisted laparoscopic BPD/DS. Background: Small bowel Obstruction is a rare complication after Methods: Patient is placed supine on the operating table. A 15 mm, Roux – en y gastric bypass surgery for morbid obesity. Common three 12mm and two 5mm ports are placed in the upper abdomen. causes include internal hernias, adhesions and kinking of the Creation of gastric sleeve is started 6-8cm proximal to the pylorus jejunojejunostomy . using linear staplers and guided by an intragastric 42Fr bougie. One of the rare etiology of small bowel obstruction at early post Suture line is imbricated with 2-0 nonabsorbable sutures. Duodenal operative time is performing jejunojejunal anastomosis in Roux limb dissection is started about 3cm distal to the pylorus and transection is to itself instead of anastomosis between Roux and billiopancreatic completed with a 60mm linear stapler. A mark is made 100cm limb of the jejunum. proximal to the terminal ileum and a subsequent 150cm of small The etiology maybe low exposure and working space and careless. A bowel loop is measured from this point which is then brought up in delay in the diagnosis and management may result in catastrophic an antecolic fashion as alimentary limb. Posterior outer layer of outcomes. Therefore the teams of bariatric surgery should involved as duodenoileal (DI) anastomosis is then created. Next, ileoileal (II) soon as possible and do the best management for resolving problems. anastomosis is completed using two 60 mm linear staplers. The small Methods: We describe the clinical and radiologic presentation of a bowel mesenteric defect is carefully closed. Da Vinci robotic system case of billiopancreatic limb obstruction due to Roux limb is then docked for completion of a two layered DI anastomosis. An jejunojejunal anastomosis at early post operative time (5 days after abdominal drain is placed routinely in the right upper quadrant operation). following a negative methylene blue leak test. Results: After diagnosis of billiopancreatic limb obstruction at 5th Results: A total of 42 cases have been successfully performed using day of surgery, we reoperated the patient and performed a new this technique. Average BMI and operative time were 50.2 and 322 anastomosis between Roux and billiopancreatic limb and the patient minutes respectively. Length of stay was 3.4 days without recovered and left the hospital after 5 days. intraoperative and 30-day major complications. Conclusion: We recommend our colleagues to review the film of Conclusion: Robotically assisted laparoscopic BPD/DS is a safe and operation as soon as possible after surgery to prevent loosing time for feasible alternative technique in minimally invasive bariatric surgery. diagnosing any complication

P-053 The Effects Of Gastric Banding On Idiopathic (Benign) (0.25 mg/kg), an exogenous agonist of CB1 receptors, on ghrelin Intracranial Hypertension. plasma concentration and on ghrelin immunoreactivity in the gastric mucosa of male Wistar rats. PRESENTER: Richard Egan (Southmead Hospital) Methods: Four hours after a single injection of both cannabinoids or vehicle, the animals were anaesthetized and blood was taken from the Co-authors: Richard Bromilow1, Hayley E. Meredith1, Sally Norton1, abdominal aorta to determinate plasma ghrelin concentration by RIA. Justin Morgan1 Subsequently, the animals underwent resection of distal part of stomach. Immunohistochemical study of gastric mucosa, using the

EnVision method and specific monoclonal antybodies against ghrelin 1. Institute of Bariatric Surgery, Southmead Hospital, Bristol, United was performed. The intensity of ghrelin immunoreactivity in X/A- Kingdom. like cells was analyzed using Olympus Cell D image analysis system. Results: The attenuation of ghrelin–immunoreactivity of gastric Background: Idiopathic intracranial hypertension (IIH) is a disease mucosa, after a single injection of R-(+)-methanandamide and CP that affects predominantly overweight or obese, pre-menopausal 55,940 was accompanied by a significant increase of ghrelin plasma women. Its cause is unknown, and it is associated with symptoms concentration. such as headache, visual disturbances, and tinnitus. Medical Conclusion: These results indicate that stimulation of appetite exerted management is largely based around symptom control, and by cannabinoids may be connected with an increase of ghrelin occasional neurosurgical intervention is indicated for intractable secretion from gastric X/A-like cells. symptoms. There is some evidence that gastric bypass leads to significant improvements in patient outcome but there is little such evidence for gastric banding. P-055 Cognitive Errors Related To Hyperprotein Eating Methods: A cohort of 4 patients with idiopathic intracranial Behaviour: Are They Cognitive Traps For The Balance Of hypertension and morbid obesity that were treated with gastric Healthy Eating And Effective Weight Loss? banding was identified from a central database. Medical records were reviewed retrospectively and patients were interviewed with a standardised telephone questionnaire. PRESENTER: Anna Chatzidimitriou (Athens Medical Centre) Results: All patients within this group showed either complete Co-authors: Marina G. Chaida1 symptom resolution (2/4 patients) or significant improvements in symptoms (2/4 patients) within two months of gastric banding. One patient with a pre-existing visual field defect had persistence of the 1. Robotic, Bariatric & Laparoscopic Surgery Clinic of Dr defect but demonstrated dramatic improvements in visual acuity. Konstantinidis, Athens Medical Centre, Marousi- Athens, Attica, Weight loss was in line with that expected for gastric band patients, Greece. with an average excess body weight loss of 53.88% (16.86%- 78.15%) at an average of 14.9 months post-operatively. There was Background: Cognitive errors are involved in a number of one band slip that required re-banding. psychological disorders and their effect on the maintenance of these Conclusion: Gastric banding appears to offer significant disorders is well established by studies (Zijlstra et al, 2006). improvements in the symptomatic control of IIH. Symptomatic Furthermore, cognitive errors are present in eating disorders, such as improvements, and in some cases, resolution, is apparent from an Bulimia Nervosa and BED (Toner et al, 1987). Candidates for early stage post-operatively. This, in fact, occurs even before a bariatric surgery often have a co morbidity of BED and have made in significant drop in weight is seen in such patients. Gastric banding the past significant attempts for loosing weight with different types of should be considered an excellent intervention for this difficult ―fab‖ or not diets. Through their diet efforts, not only weight loss and condition. body composition is affected but behaviors, cognitions and emotions are shaped differently to each individual. The aims of this ongoing 10 month study are: a) to assess and code the presence of cognitive error P-054 Cannabinoids Enhance Gastric X/A – Like Cells Activity mechanisms that may relate to a hyperprotein eating behaviour or other unbalanced nutrition related behaviors and b) to assess the % of PRESENTER: Robert Zbucki (Medical University in Bialystok) fat loss and compare it to total weight loss. Methods: The study protocol involves a total of 50 patients Co-authors: Hady Razak Hady1, Boguslaw Sawicki3, Jacek Dadan1, undergoing LAGB surgery at the center. Patients‘ previous diet Maria Winnicka2 attempts to lose weight has been assessed, and a coding of their cognitive errors has been made. Patients are entered into a repeated measures design, followed for 10 months after surgery, and have their 1. 1st Department of General and Endocrinological Surgery, Medical body composition examined every 3 months post- operatively using University in Bialystok, Bialystok, Poland. the bioimpendance analyzer ―Biodynamics BIA 310e‖. The relation 2. Department of General and Experimental Pathology, Medical of the above weight loss measures, the groups of cognitive errors and University of Bialystok, Bialystok, Poland. previous diet attempts will be examined. 3. Department of Histology and Embryology, Medical University of Results: Preliminary results indicate that patients with cognitive Bialystok, Bialystok, Poland. errors related to nutrition and previous hyperprotein or fab diet attempts, have undesirable % of fat loss, most likely due to lack of Background: It has been reported that cannabinoids may cause compliance to medical and nutritional advice. overeating in humans and in laboratory animals. Although, Conclusion: The above findings are discussed in relation to potential endogenous cannabinoids and their receptors (CB1) have been found psycho-educational interventions for improved future outcomes. in the hypothalamus, and recently also in gastrointestinal tract, the precise mechanism of appetite control by cannabinoids remains unknown. Recently, ghrelin – a hormone secreted mainly from the P-056 Analysis of The Weight-Reducing And Metabolic Efficacy stomach X/A-like cells was proposed to be an appetite stimulating Of Laparascopic Sleeve Gastrectomy agent. The aim of this study was the evaluation of the influence of a single ip injection of a stable analogue of endogenous cannabinoid – anandamide, R-(+)-methanandamide (2.5 mg/kg) and CP 55,940 PRESENTER: Daniel Del Castillo (Rovira i Virgili University. University Hospital of Sant Joan. IISPV, Reus, Spain) a lot of postoperative complications. Background: Sleeve Gastrectomy (SG) is a technique whose results have been studied by various groups. The aim of this study is to assess the efficacy and reliability of this technique in terms of loss of P-058 Biopsychosocial Factors Of Gastric Banding Patients In A weight and improved metabolic syndrome in morbid obesity patients Greek Population operated in our Hospital. Methods: Ninety-five patients operated between 2004 and 2009 were PRESENTER: Marina Chaida (Athens Medical Centre) analysed by means of the SG technique. The indications were: BMI between or greater than 50 to 55 kg/m2; lesser BMI values with Co-authors: Anna Chatzidimitriou1, Konstantinos M. Konstantinidis1 serious comorbidities or significant hepatomegalies, and in adolescents. 1. Robotic, Bariatric & Laparoscopic Surgery Clinic of Dr Results: Mean BMI 51.6 kg/m2. Comorbidities: type 2 diabetes Konstantinidis, Athens Medical Centre, Marousi- Athens, Attica, mellitus (38%); blood pressure (69%); dyslipemia (20%); SAOS Greece. criteria (49%), depression (40%), and chronic venous insufficiency (20%). Complications: 3 patients suffered from major complications (1 case of gastric volvulus and 2 cases of respiratory complications) Background: Cross-cultural differences in obesity have been found in and 6 patients reported less serious complications (2 cases of a wide range of previous studies and have become the object of great dysphagia, 2 cases of intra-abdominal ascites, 2 cases of subclinical attention in the research field. As Greece constitutes, according to the effusions from the line of staples). Overall mortality was 1% (1 death World Health Organization (WHO), the second highest country in due to respiratory failure). We observed improvements in all Europe in morbid obesity, and among the first few countries variables analysed, both clinical and biochemical, and these were worldwide, a well- established evaluation in the biopsychosocial statistically significant for the BMI, glucemia, and triglyceridemia factors, leading Greeks to obesity is highly significant. (P<0.001) during the period of 1 year following surgery. The basic aim of the study was to assess and analyze numerous Conclusion: SG is an excellent procedure to treat morbid obesity. It factors gathered from different health professionals of the bariatric leads to improvement or cure of the metabolic syndrome during the team, so as to demonstrate the factors‘ effect on the actual patients‘ first 18 months and is statistically significant for triglycerides and weight loss in the time period of one year. glucose. Patients with BMI > 50 kg/m2 may present insufficient The main factors analyzed were psychological, behavioural, weight loss and require the association of a malabsorptive technique. nutritional, demographic, cognitive and medical. Methods: The study protocol involves a total of 70 patients undergoing laparoscopic surgery for morbid obesity (with lap-band) at Athens private Medical centre. Patients are entered into a ―before P-057 Complications After Laparoscopic Adjustable Gastric and after‖ design, followed for 12 months after surgery. Baseline Banding (LAGB) Operations measures include psychological, nutritional and medical factors, drawn from semi- structured diagnostic interviews. PRESENTER: Hady Razak Hady (Medical University in Results: The preliminary results denote a trend of the multifactorial Bialystok) profile of the Greek obese patient. Conclusion: The above findings are discussed in the context of the Co-authors: Jacek Dadan1, Robert Zbucki1, Pawel Iwacewicz1, 1 1 multidisciplinary assessments conducted at the center. An effort for a Pawel Golaszewski , Jerzy Ladny prediction model of the correlated factors will be made. Possible interaction among psychological and nutritional/diet factors will be 1. 1st Department of General and Endocrinological Surgery, Medical examined and its effect to weight loss. University in Bialystok, Bialystok, Poland.

Background: Complications after bariatric procedures depend on type P-059 Quality Of Life After Surgical Treatment Of Morbid of operation and comorbidites. Intra- and postoperative complications Obesity were estimated at 2 to 20 %. The morbidity in perioperative period is about 2%. The most often complications are: circulatory and PRESENTER: Hady Razak Hady (Medical University in respiratory insufficiency, pulmonary thrombosis, bleeding, damage of Bialystok) spleen and liver, migration of band, infection of port location, perforation of stomach. Methods: The aim of our study was retrospective analysis of Co-authors: Jacek Dadan1, Pawel Iwacewicz1, Robert Zbucki1, Pawel complications after LAGB method. From May of 2005 to 2009 Golaszewski1, Piotr Wojskowicz1 LAGB procedure was performed in 71 (45 female, 26 male) morbidly obese patients at age from 18 to 61 (mean – 46), BMI 41-52 (mean 1. 1st Department of General and Endocrinological Surgery, Medical 45.5). University in Bialystok, Bialystok, Poland. Results: In 2 (2.8%) patients stomach rotation because of peritoneal adhesions and upper gastrointestinal tract obstruction symptoms (vomiting, dehydratation, electrolytes deficiency) were observed 3 Background: Morbid obesity leads to decrease of quality of life. and 15 months after LAGB with reduction of body weight 35 and 71 Bariatric Analysis and Reporting Outcome System (BAROS) was kg respectively. Migration of band with obstruction symptoms in 2 created to objective evaluation of results of bariatric surgery. (2.8%) patients was noted 11 and 19 months after operation. In one The purpose of our study was the evaluation of late results of surgical case pneumonia with left pleural abscess was observed 7 days after treatment of morbid obesity after laparoscopic adjustable gastric surgery. In one patient 3 months after LAGB the infection of port banding – LAGB and Roux-y-gastric bypass – RYGB procedures, location was noted. Another complication was slippage of gastric together with evaluation of quality of life in postoperative period. band to pyloric region of stomach observed 4 months after LAGB Methods: 60 patients were included to the study. 30 patients at mean with 60 kg decrease of body weight. age 34±9.67, mean BMI 44.3±3.7 were treated with LAGB method. Conclusion: In our opinion LAGB is efficient option to achieve The rest patients at mean age 50.9±7.8 and mean BMI 54.5±6.72 weight loss in morbid obesity patients. LAGB is shorter and cheaper undergo RYGB method. All patients were operated between 2007 procedure in comparison to another types of bariatric surgery, but has and 2008 years. Questionnaires according to BAROS, in our modification, 6 or more months after surgical procedures were given 1. Rovira i Virgili University. University Hospital of Sant Joan. to patients. IISPV, Reus, Spain. Results: The results of surgical treatment in 17% of all patients was excellent, in 57% very good, in 23% good, in 1.5% fair and in 1.5% Background: Intestinal intussusception in the adult is a rare cause of failure. In final evaluation of quality of life together in both groups it intestinal occlusion. We report a case of intestinal intussusception in was much better in 55% of patients, better – 42%, in 3% it was a pregnant female with a history of Roux-en-Y gastric bypass unchanged performed 5 years earlier for morbid obesity. Conclusion: Morbidly obese patient‘s quality of life, after the most Methods: Twenty-eight-year-old female patient, 35 weeks pregnant, often so far performed laparoscopic as well classic bariatric admitted to the obstetrics and gynecology department for acute procedures, evaluated 6 or more months after operation, considerably abdominal pain in the left hypochondrium. The patient presented improves. general discomfort, repeated vomiting, and leukocytosis with neutrophilia upon blood analysis. Abdominal ultrasound revealed dilatation of intestinal sections. Due to the gradual worsening in P-060 Partial Splenic Infarction In The Context Of A Sleeve clinical condition and the suspicion of intestinal occlusion, an Gastrectomy emergency caesarean section was performed with explorative laparotomy. This revealed a 90 cm entero-enteric small intestinal PRESENTER: Daniel Del Castillo (Rovira i Virgili University. intussusception by means of jejuno-jejunal anastamosis with necrosis University Hospital of Sant Joan) of the invaginated intestinal segment. This was removed and an end- to-end anastomosis was performed. Co-authors: Maria Socías1, Fàtima Sabench1, Mercè Hernández1, Results: During the post-operative period the patient presented torpid Santiago Blanco1, Margarida Vives1, Arantxa Cabrera1, Antonio progression with clinical symptoms of fever, difficulty breathing, and Sánchez1 abdominal pain. Computed tomography revealed the existence of free intraperitoneal fluid. We decided to operate again and observed a 1. Rovira i Virgili University. University Hospital of Sant Joan, Reus, superinfected intraperitoneal hematoma; we performed washes of the Spain. intestinal cavity and put drains in place. The patient progressed favourably with oral tolerance and was discharged 21 days following

hospital admission. Background: Partial splenic infarction is a possible condition in the Conclusion: Intestinal intussusception in the adult in the context of context of a sleeve gastrectomy although this is rare and barely bariatric surgery is an exceptionally late complication. In 85% of the documented. Its origin lies in the vascular compromise of short blood cases reported pathogenesis is tumour-related although significant vessels. We report the case of a 50-year-old patient whose only loss of weight is also reported. In these cases early diagnosis and medical history includes morbid obesity with a BMI of 43.5 kg/m2. treatment are vitally important. Methods: The patient was operated electively; a sleeve gastrectomy was performed by means of laparoscopy. No technical incidences occurred. The immediate post-operative period occurred without incidence. P-062 Cognitive-Behavior Therapy And Gastric Banding Gastroduodenal-esophageal transit after 24 hours revealed correct Surgery: A Case Study Of A Multidisciplinary Approach Of A17 penetration of contrast. y.o. Morbid Obese Patient With Binge Eating Disorder On the 4th post-operative day the patient complained of fever (37.8 C) and slight abdominal pain. Blood analysis: 13 000 leukocytes with PRESENTER: Anna Chatzidimitriou (Athens Medical Centre)

80% neutrophils, fibrinogen > 7, and PCR of 152. Computed 1 1 tomography (CT) revealed an internal hypodense image in the Co-authors: Marina G. Chaida , Konstantinos M. Konstantinidis superior pole of the spleen which indicated an area of infarction with a small amount of antero-splenic fluid. 1. Robotic, Bariatric & Laparoscopic Surgery Clinic of Dr Results: Antibiotic treatment commenced and a hopeful attitude was Konstantinidis, Athens Medical Centre, Marousi- Athens, Attica, maintained. The patient's symptoms and analysis improved following Greece. completion of treatment and they were discharged on the 14th day post-operatively. The patient continued to progress favourably and Background: Bariatric surgery is a popular procedure in Greece has been symptom-free to date. because of its minimal invasion and its efficacy to the treatment of Conclusion: Splenic infarction is a rare complication following morbid obesity. Studies have been shown body fat reduction after the sleeve gastrectomy but should be considered in cases of torpid first year of surgery up to 50% of the initial weight (Kuneth et al. evolution post-operatively. The imaging test of choice for its 1996; Neef et al. 1996). Research on psychological effects of diagnosis is CT. The anatomical anomalies of splenic vascularization bariatric surgery is fairly recent and has found that patients report may justify these symptoms; treatment is conservative except when improved quality of life (e.g. De Zwann et al., 2002), reduced evolving into an abscess in which case splenectomy would be psychological mobidity such as depression and emotional distress indicated. (e.g. van Gemert, et al,1998; Vallis et al, 2001). Methods: Cognitive Behaviour therapy was introduced after first week of surgery and the therapeutic stages included the treatment of P-061 Entero-Enteric Intussusception During Pregnancy In A binging eating disorder and the incorporation of cognitions and Patient With Roux-En-Y Gastric Bypass behaviour observations related to gastric banding surgery. The inventories that were given before-after surgery were all standardized PRESENTER: Daniel Del Castillo (Rovira i Virgili University. in Greek population and are the following: Beck Depression University Hospital of Sant Joan) Inventory, STAI-SPIELBER, WHOQOL-BREF, General Health Questionnaire, 16-item Health Locus of Control Scale. Co-authors: Arantxa Cabrera1, Margarida Vives1, Antonio Results: Preliminary results indicate that cognitive-behavior therapy Morandeira1, Jesús Sánchez Pérez1, Santiago Blanco1, Mercè in relation to gastric banding can contribute to reduce binging eating Hernández1, Antonio Sánchez1, Luisa Piñana1, Maria Socías1, Fàtima episodes, reduce body fat more than 50% at the first year after Sabench1 surgery and can improve psychological morbidity in terms of quality of life, depression and anxiety levels. Conclusion: The above findings are discussed in the context of the Methods: The EndoGIA linear transection of the stomach is strictly multidisciplinary assessments conducted at the center and the way performed 2 cm away from the position of the band, to avoid they may inform about the antecedents of the above observations as thickness of the gastric wall. In addition the green cartridges are used well as about potential interventions for improved future outcomes. for the fire (we are normally using blue ones). The single step conversion was not considered in patients with band complications for the high risk of complications. Results: From 2002 to 2009 in two high volume bariatric centres we P-063 Effects Of Experimental Duodenal Exclusion By Means Of have performed 2834 gastric bandages. Physical Barrier: Preliminary Results We have carried out 64 (2,24%) LRYGBP as rescue procedures for insufficient weight loss (EWL<30%) with residual BMI ≥40. PRESENTER: Daniel Del Castillo (Rovira i Virgili University. No conversion to open surgery, no leaks, no major complications. University Hospital of Sant Joan IISPV) The post-operative course was comparable to the elective LRYGBP. In 3 patients (4,6%) the RYGBP was performed in a two-step surgery Co-authors: Fàtima Sabench1, Mercè Hernández1, Arantxa Cabrera1, for local anatomical impediment. Margarida Vives1, Maria Socías1, Santiago Blanco1, Antonio Conclusion: Bariatric revisional surgery is a major concern. Sánchez1 Adhesions from previous surgery and thickness of tissue, are increasing the possibility of complications. Staple line insufficiency

or disruption are the most serious ones. 1. Rovira i Virgili University. University Hospital of Sant Joan. In our experience, the bariatric revisional surgery with conversion to IISPV, Reus, Spain. LRYGBP ― one step‖ achieves the same excellent results in term of lose of weight, with the same percentage of morbidity of the Background: The aim of surgical treatment of morbid obesity is to operation performed in election. comply with expectations regarding weight and metabolic results. Duodenal exclusion forms part of the pool of techniques which comprise metabolic surgery as a new discipline. The aim of this paper is to reveal the preliminary results in experimental animals as to P-065 Fast Track Postoperative Management In Bariatric weight variation and intake. Surgery Methods: Male Sprague-Dawley animals aged 9 weeks. Group 1 sham and group 2 duodenal exclusion. Surgical intervention: gastrotomy proximal to the pylorus (0.5 cm). Placement of a 10 cm PRESENTER: Daniel Del Castillo (Rovira i Virgili University. polyethylene tube fixed at its distal and proximal extremity. University Hospital of Sant Joan. IISPV) Extraction of blood prior to and following surgery. Determination of Co-authors: Margarida Vives1, Arantxa Cabrera1, Mercè Hernández1, weekly glycemia. Indirect calorimetry before and after the operation. Fàtima Sabench1, Santiago Blanco1 Results: Mean reduction in intake of 5 g/d/rat (20%) during the first 2 weeks following surgery in the intervention group. Weight: Significant reduction in mean values following surgery in the 1. Rovira i Virgili University. University Hospital of Sant Joan. intervention group below the corresponding weight curve related to IISPV, Reus, Spain. chronological age (9% absolute weight loss). Glycaemia: Significant reduction in mean values prior to and Background: With the progressive development of minimally following surgery in the intervention group considering that these are invasive surgery, the Fast Track concept has appeared in the last not diabetic rats (decrease in mean of 128 mg/dL to mean of 105 years. Fast track or multimodal rehabilitation is a combination of care mg/dL) plans designed to reduce the perioperative stress response, improve Conclusion: These results are subject to the basal condition of no the pain control, facilitate early recovery and early patient discharge. obesity. The second phase is in the process of being performed by The aim of our Fast Track postoperative management protocol for applying the same protocol in obese animals fattened-up by means of patients that undergo bariatric surgery is to achieve an early recovery a 4-week cafeteria diet. with no impact in morbi-mortality taxes Methods: A continous control and the continous change of decissions, are the main factors in the justification of the fast track. P-064 Laparoscopic Revisional Bariatric Surgery: A “Single The use of peroperative intermitent pneumatic compression, low Step” Procedure From Failed Band To LRYGBP. molecular weight heparin and early mobilisation prevents the thrombotic events. Chest physiotherapy in the immediatly PRESENTER: Fabrizio Bellini (Bariatric and Metabolic postoperative period prevents the development of atelectasis. Early Surgery) detection of anastomotic leaks by performing upper gastrointestinal transit in the first 24 hours. Results: In abscence of anastomotic leaks the nasogastric tube is Co-authors: Pietro Pizzi2 removed and a liquid diet started with strict control of the drain. If the productivity is minimal and have a good aspect, the drain is removed

in 48 hours. 1. Surgery, Bariatric and Metabolic Surgery, Desenzano (BS), Italy. Conclusion: Morbid obesity carries a large number of comorbidities. 2. Obesity Surgery, Policlinico Monza, Monza, Italy. The use of these methods on these highly complex patients optimise the functional recovery and improve the surgical outcome, with early Background: Restrictive bariatric procedures like LAGB may have a patient dicharge and less morbidity. long term failure of losing weight up to 40% of patients. In case of EWL <30% and high residual BMI, is required a revisional bariatric surgery. The conversion from failed LAGB to LRYGBP in one step is our P-066 Small Erosion Of Laparoscopic Adjustable Gastric Band: gold standard treatment. Endoscopic Removal Through Incision In Gastric Wall The aim of this study is to demonstrate the possibility to perform the revisional bariatric surgery in ―one step‖ with acceptable morbidity. PRESENTER: Manoel Galvao Neto (Gastro Obeso Center) intolerance 20 (0.57%). Co-authors: Josemberg M. Campos1, Luis F. Evangelista1, Joao Paulo 1 2 1 Conclusion: The perigastric ‖two-step‖ technique is an improvement C. Martins , Almino C. Ramos , Alvaro Antonio B. Ferraz of the single step perigastric technique. It‘s a safe and effective 1. Surgery, Federal University of Pernambuco, Recife, Pernambuco, procedure, maintaining a low percentage of slippage. Brazil. With the perigastric ―two-step‖ approach we have a tight posterior 2. Gastro Obeso Center, Sao Paulo, Sao Paulo, Brazil. and lateral band support, we avoid intimate posterior gastric wall dissection and consequently zero posterior slippage. Background: The erosion of a laparoscopic adjustable gastric band (LAGB) can cause pain that is not controlled by analgesics. In such cases, early endoscopic removal may be indicated, but only when gastric penetration is greater than 50%. P-068 Incidence Of Occult Deep Vein Thrombosis In Bariatric Methods: We report the case of a patient with severe shoulder pain Surgery: Prospective Clinical Trial Using Doppler Ultrasound due to a small area of LAGB erosion, which was treated with early And Blood Screening. endoscopic removal through an incision in the gastric wall. Results: Laparoscopy did not initially succeed in removing the band PRESENTER: Dieter Birk (Protestant Hospital) due to peritoneal adherences. The pain worsened after eating and gastroscopy revealed slight gastric erosion of the band under the Co-authors: Peter Djalali1, Sebastian Hollaender1 cardia. The gastric wall covering the LAGB was incised using an endoscopic needle knife, which allowed greater penetration of the 1. Surgery, Protestant Hospital , Zweibruecken, Germany. band and immediate pain relief. In a second upper endoscopy performed under deep sedation seven days later at the endoscopy suite, endoscopic scissors were used to cut the thread and part of the Background: Thromembolic complications are still one of the leading band lock. The open band was then removed orally. causes for perioperative mortality in bariatric surgery. The aim of this Conclusion: This novel endoscopic incision in the gastric wall prospective study was to identify patients at risk to suffer from such a hastened band erosion, relieved the shoulder pain and avoided complication. abdominal reoperation. Methods: Patients and methods: 85 consecutive patients who were scheduled for a bariatric procedure (LAGB n=12, Sleeve resection n=30, Y-roux bypass n=43) underwent preoperative lab testing searching for coagulation defects as well as preoperative Doppler P-067 Gastric Band: The Perigastric “Two-Step” Technique To ultrasound of the deep vein system of the lower extremities Prevent Posterior Slippage. Results After 3492 Patients. preoperative, after 2 days and 3 month after the operation. During the hospital stay patients received 80 mg Enoxoparin s.c. per day PRESENTER: Fabrizio Bellini (Bariatric and Metabolic Results: 4 of 85 patients had previously unknown risk factors for Surgery, Desenzano) thrombembolic complications (3 patients with apc-resistance, 2 2 3 4 patients with Protein C deficiency) Co-authors: Pietro Pizzi , Marco Zappa , Gianfranco De Lorenzis Using Doppler ultrasound 2 patients were found to have isolated thrombosis of the superficial venous system, deep vein thrombosis 1. Surgery, Bariatric and Metabolic Surgery, Desenzano, Desenzano was neither pre- or postoperatively encountered (BS), Italy. Conclusion: Further reduction of thrombembolic complications in 2. Surgery, Bariatric Surgery, Monza, Italy. bariatric surgery is desirable. This study examined the possibility of 3. Surgery, Policlinico , Milano, Italy. lab-screening and Doppler ultrasound to identify persons at risk apart 4. Surgery, Clinica Città di Parma, Parma, Italy. from previous incidence or family background. 4 of 85 patients were found to have previously unknown coagulation defects and were Background: The Laparoscopic Adjustable gastric Band is the therefore further examined before the surgical intervention took bariatric restrictive procedure with the most increasing development place. Doppler ultrasound could not identify so far unknown deep in the world. Different techniques are used for the implantation of vein thrombosis, an unexpected result at this point of the study. this device. Nevertheless we feel that this increased effort in time and cost will Our purpose is to emphasize the advantage of the perigastric‖two- help to identify patients at risk and further lead to a decrease of the step‖ procedure compared to the ―pars flaccida technique‖ in the feared complication prevention of the typical complication of the gastric band: the slippage. Methods: We retrospectively reviewed our obesity surgery data base. P-069 Effect Of Duodenojejunal Bypass Associated With Ileal It‘s a multicentre study and the outcomes of 3492 patients are Interposition Without Gastric Resection On Glucose Metabolism evaluated. We analyse the results evaluating all the complications, but with PRESENTER: Eduardo Crema (University Hospital, Federal particular attention to the slippage. University of Triângulo Mineiro (UFTM)) The old ―one step perigastric technique‖ was changed into the ―two- step‖ perigastric technique‖. Results: From January 2001 to January 2009, 3498 patients( 2853 Co-authors: Fernanda B. Dijigow1, Maria Gabriela F. Figueiredo1, female, 645 male) underwent LAGB (Heliogast® System). Juverson A. Terra1, Alex A. Silva1 Initial mean BMI was 43.9 for male, 41.9 for female. At 5 years was 30.6 for male, 30.1 for female, with 54,5% of EWL. 1. Department of Digestive Surgery, University Hospital, Federal No intraoperative or postoperative deaths. Conversion rate: University of Triângulo Mineiro (UFTM), Uberaba, Minas Gerais, 4(0.114%). Brazil. Trocar site bleeding: 4(0.114%). No posterior slippage. Slippage (only anterior): 158( 4.5%).Long term major complications: intragastric migration 19 (0,54%), trocar hernias 39 (1,11%), port Background: Inhibition of the secretion of triggers of insulin disconnections or tube injury 47 (1,.3%), failure to lose weight resistance is attributed to duodenojejunal bypass of nutrient transit (<25%EWL) 202(7,08%), band removal for psychological and production of hormones that improve insulin action and stimulate the proliferation of pancreatic cells to the early arrival of nutrients in Number Age in Length Weight BMI the ileum. Objective: Patients with DM2 (body mass index, BMI: 26 LSG of BMI yrs of stay reduction reduction to 35 kg/m2) were submitted to the mixed technique. group patients (range) (Range) (days) at 1 year at 1year Methods: Methods: Twenty adult patients with more than 2 years (females) since the diagnosis of DM2 ranging in age from 18 to 60 years and Group 42(21- 60( 50- receiving insulin therapy were submitted to videolaparoscopic 59 (37) 4 42.4kg 14 surgery consisting of the interposition of an ileal segment of 100 - 70 1 >50 61) 82) cm from Treitz‘ angle and exclusion of a 100-cm duodenojejunal Group 40(24- 40(34- 49 (43) 2.5 36 kg 12 segment without longitudinal gastrectomy. 2 <50 60) 48 ) Results: Results: Mean age was 51.6 years (31-60) and 13 patients were females. The mean duration of diabetes was 12.3 years (5-17). Weight loss of 8.14% was observed after surgery (71.27 kg) compared to the preoperative period (77.59 kg). The mean BMI was P-071 The Search For Factors That Might Influence Weight Loss 29.56 and 27.33 kg/m2 before and after surgery, respectively. Fasting After lrygb: Does Inflammation Matter? glycemia was 218.08 mg/dl (127.1-371.8) before and 121.6 mg/dl (52.5-154) 6 months after surgery. Postprandial glycemia was 309.02 PRESENTER: Gil Faria (Hospital Sao Joao) mg/dl (193.3-584) before and 149.4 mg/dl (64.5-197.8) after surgery. Mean preoperative glycated hemoglobin (10.02 mg/dl, 7.2-15.6) was Co-authors: John R. Preto2, Antonio Gouveia2, Jose Barbosa1, reduced to 7.15 mg/dl (5.78-9.1). All 10 insulin-dependent patients Silvestre Carneiro1, Eduardo L. Costa2, Cristina Teixeira2, Cidalia who required a mean dose of 47.07 U/day (150-30) before surgery Gil2, Joaquim Sousa-Rodrigues2, Joaquim Oliveira Alves2 required 23.13 U/day (49-8) after surgery, corresponding to a reduction of 49.14%. Seven of the 10 cases who did not require 1. Cirurgia Geral, Faculdade de Medicina do Porto, Porto, 0, insulin after surgery were using oral hypoglycemics after 6 months Portugal. and 3 did not require any medication for glycemic control. 2. Unidade Tratamento Cirúrgico de Obesidade - Serviço de Cirurgia Conclusion: The surgery proposed was effective in the control of Geral, Hospital Sao Joao, Porto, Portugal. glycemia and should be recommended for diabetic patients with a BMI < 85 kg/m2. Background: To determine preoperatively which patients would benefit most from bariatric surgery could help surgeons to P-070 Outcomes Of Sleeve Gastrectomy As A Single Stage appropriately select patients for treatment. The inflammatory burden Procedure For <50 Bmikg/M2 Compared To First Stage For >50 has been associated with metabolic syndrome but no known study has Bmikg/M2 analyzed its influence in surgical outcomes. Methods: Retrospective analysis of the clinical records of 47 consectuive patients with more than 6 months of follow-up. We used PRESENTER: Kalpana Devalia (Homerton University Hospital) mean values of CRP to stratify patients in 2 groups: higher inflammatory status (HIS: CRP=>10mg/L) and lower inflammatory Co-authors: Samrat Mukherjee1, Mehtab Rahman1, Harun Thomas1, 1 status (LIS: CRP<10mg/L). We analyzed outcomes at 6 and 12 Kesava Reddy Mannur months post-operatively. Results: The mean pre-operative weight was 121,7kg (mean BMI of 1. Homerton University Hospital, London, United Kingdom. 45,9kg/m^2). The mean CRP value was 10,31mg/L and only 8,6% of patients had a ―normal‖CRP value (<3mg/L). The initial BMI was Background: Laparoscopic Sleeve Gastrectomy(LSG) is becoming 45,9 for LIS and 48,2 for HIS; p=0,16. The BMI, total amount of more popular as medium term results are comparable to Roux-en-Y weight lost (TWL) and % of excess BMI lost (%EBL) according to gastric bypass. We aim to compare the outcomes in terms of weight each group, is represented in Table 1. loss of patients with BMI <50kg/m2 and those with BMI>50 who Most (68,8%) patients of the LIS group achieved BMI<30kg/m^2, underwent a LSG. compared to 37,5% in the HIS group (p=0,2). There is a significant Methods: We identified all patients who underwent LSG from 2005 negative correlation between the CRP value and the lost weight at 12 to 2008, from our prospectively maintained database: Group 1 with months (-0,509; p=0,01). BMI >50 who underwent LSG as part of a 2-stage procedure and Conclusion: The patients in the high-CRP group had a reduced Group 2 with BMI <50 who underwent LSG as a single stage amount of weight lost at 12 months. However, this did not translate in procedure. We analysed the morbidity, length of stay, Weight loss a statistically significant change in %EBL or achieved BMI. The and BMI reduction following the initial procedure majority of patients in the low-CRP group achieved a cure for obesity Results: Group 1 had 59 patients. Median BMI was 60 and median (BMI<30). There is a correlation between increased CRP and age 42years. 37 were females (table ) impaired weight lost at 12 months. Group 2 had 42 patients. Median BMI was 40 and the median age 40 years and 37 were females. The average length of stay was 4 days in group 1 and 2.5 days in Table 1 group 2. 6 months p 12 months p Complications occurred in 6 patients (10%) in group 1 and 4 patients LIS HIS LIS HIS needed re-laparoscopy for staple line abscess, leak or bleeding. There was no mortality. Median weight loss at 1 year in group 1 was 42.4kg BMI (kg/m^2) 32,9 34,8 0,383 29,6 32,6 0,315 and median BMI reduction was 14. TWL (kg) 34,0 28,7 0,187 45,4 32,4 0,008 Group 2 had 1 complication of port site hernia which required laparoscopy and repair. Median weight loss at 1 year in group 2 was %EBL 63,2 54,4 0,248 79,4 69,4 0,202

36 kg and Median BMI reduction was 12. Conclusion: LSG is a safe and effective procedure for the initial weight loss in both the super-obese and the obese patients. P-072 Laparoscopic Sleeve Gastrectomy Via Single Umbilical Access: Is This The Future Of Bariatric Surgery? Experience From First UK Series 6 and 9-12 months postoperative was 38±14, 29±11 and 32±10 PRESENTER: Marco Adamo (University College London respectively. Hospital) No statistical significant difference was found between preoperative SES and %EWL both at 3-6 and 9-12 months after operation. In a Co-authors: Francesca Lirosi1, James Hewes1, Mohammed univariate Analysis, the only statistically significant predicting factor 1 2 2 Elkalaawy , James Holding , Maan Hasan for %EWL after the operation was EW prior to operation (p=0.006). 1. Bariatric Surgery, University College London Hospital, London, No significant relation was found between postoperative SES score United Kingdom. and between chocolate, snacking, cakes, cookies, nuts and soft drinks 2. Department of Anesthesia, University College London, London, consumption. United Kingdom. Conclusion: Snack eating behavior does not affect weight loss amongst sleeve gastrectomy patients at short term follow up. Longer

follow-up and larger sample size studies are needed. Background: Single access laparoscopic surgery (SALS) is the new frontier of laparoscopy. It utilises the umbilicus as sole access for camera and instruments avoiding other incisions in the abdominal wall. This creates new technical challenges and requires dedicated P-074 Superior Mesenteric and Portal Vein Thrombosis after training and equipment. Lap Gastric Bypass Methods: 7 female cases were selected to undergo SALS Sleeve Gastrectomy (SG). This is, to the best of my knowledge, the first UK PRESENTER: Nestor de la Cruz-Munoz (University of Miami) series. Patients had average BMI of 41 (range 37-43). After 25mm 1 1 2 transverse incision at umbilicus, SILS port (Covidien) was introduced Co-authors: Juan C. Cabrera , Melissa Cuesta , Cristina Torres and two 5mm and one 12mm trocars were inserted through it. A standard SG (calibrated over 32Ch-Bougie) was then performed. 1. Surgery, University of Miami, Doral, FL, United States. Stomach was mobilised using ultrasonic coagulation and stapling was 2. Internal Medicine, Bronx Lebenon Hospital Center, Bronx, NY, commenced 6cm from pylorus using Echelon-Flex stapler (Ethicon- United States. EndoSurgery) with Seamguard (Gore) as staple line reinforcement. Because of single access, a 5mm 30° long camera was used and Background: Superior mesenteric vein (SMV) thrombosis and portal articulating graspers were employed to manipulate stomach; liver vein thrombosis post gastric bypass surgery is an unusual event. retraction was achieved by trans-abdominal sutures. There are no reported cases in the english literature. This Results: All cases were completed with single access. No additional complication should present similarly to trocars or incision were required. Mean operating time was 81min other events with acute bowel venous ischemia. (range 55-120), within the range of conventional laparoscopic SG Methods: Out of over 2000 roux-en Y gastric bypass done by one with minimal blood loos. Postoperative was uneventful with hospital surgeon, the chart of one patient who developed SMV and portal vein stay of 48-72hrs, no complications or readmissions. Average thrombosis was reviewed. A literature search was conducted focusing postoperative 3-months BMI was 34. At follow-up no visible on the incidence of abdominal scar was appreciable in any patient. superior mesenteric vein thrombosis and portal vein thrombosis after Conclusion: Single Access can be employed in bariatric surgery for gastric bypass. SG without increasing operating time or complications. Because of Results: The patient presented to the ER 10 days after an uneventful significant technical challenges proficiency in laparoscopic SG and laparoscopic gastric bypass surgery with 1 day history of severe careful case selection is highly recommended. abdominal pain, bloody stools and hematemisis. A CT scan showed both superior mesenteric vein thrombosis and portal vein thrombosis and evidence of small bowel P-073 Sweet-Eating And Snack-Eating Behavior Does Not Affect ischemia. At the time of surgery, severe small bowel ischemia was Weight Loss Amongst Sleeve Gastrectomy Patients found. Excision of 166cm necrosed bowel (Roux Limb) and reversal of the roux-en Y gastric bypass were performed and she recovered PRESENTER: Andrei Keidar (Hadassah Medical center) after a 10 day hospital stay. At 18 month follow-up she had no further complications. She has lost 59% of her excess weight and reports Co-authors: Chaya Schweiger1, Asaf Kedar1, Ram Weiss1 early satiety after her mid-entrectomy. Further evaluation showed that she was homozygous for C677T, a hypercoagulable state. 1. Surgery, Hadassah Medical center, Jerusalem, Israel. Conclusion: SMV and Portal vein thrombosis is a rare, but possible complication after gastric bypass in patients presenting with

abdominal pain. Background: Laparoscopic Sleeve Gastrectomy (LSG) is gaining popularity worldwide as a primary operation. Snack-eating pattern is associated with poor weight loss after restrictive procedure. However, the relationship between preoperative and postoperative sweet\snack- OP-075 Acute Gastric Remnant Dilatation After Laparoscopic eating and weight loss outcome amongst LSG patients is unknown. Roux-en-Y Gastric Bypass Surgery –Primary Or Secondary? Methods: In LSG patients the operation choice was not affected by preoperative eating pattern. 79 patients (29-male, 50-female) who had PRESENTER: Kalpana Devalia (Homerton University Hospital) LSG operation filled out a questionnaire on their snack\sweet-eating 1 1 1 habits preoperatively and during a routine follow-up visits at 3-6 Co-authors: Harun Thomas , Sara Ajaz , Kesava Reddy Mannur months and 9-12 months postoperative. The questionnaire score varies between 9 and 100, with maximal score representing high 1. Bariatric Surgery, Homerton University Hospital, London, United snack-eating behavior. Correlation of theeating pattern with the Kingdom. weight loss was analysed Results: The preoperative weight, Body Mass Index (BMI) and Background: Acute gastric dilatation is an infrequent complication of Excess Weight(EW) was 120±23 kg, 43±6 kg/m2 and 52±18 kg the remnant stomach following laparoscopic roux-en-Y gastric respectively. The average Excess Weight Loss(EWL) at 3-6 months bypass for morbid obesity. Prompt diagnosis of this condition is and 9-12 months after operation was 49%±21 and 72%±33 essential to prevent further complications. We feel that it is always respectively. The average Snack-Eating-Score (SES) preoperative, 3- secondary to distal obstruction rather than a primary condition. We P-077 107 Revisionary Bariatric Operations: Indications And report our experience with this condition and its management. Outcome Methods: 4 patients with a diagnosis of acute dilatation of the remnant stomach were identified in our prospectively maintained database from a total of 600 Roux-en-Y gastric bypass operations PRESENTER: Simon Kuesters (University of Freiburg) performed from January 2004- December 2009 2 1 Co-authors: Tobias Baumann , Jodok Grueneberger , Goran Results: All the 4 patients presented with abdominal pain on liquid Marjanovic1, W. K. Karcz1 intake. One patient was admitted 2 weeks postoperatively and underwent a laparotomy for suspected internal hernia; actual diagnosis was missed. She remained symptomatic. CT abdomen 1. Visceral Surgery, University of Freiburg, Freiburg, Germany. confirmed the diagnosis and percutaneous gastrostomy performed. 2. Department of Radiology, University of Freiburg, Freiburg, The second was readmitted 4 days post-operatively and CT scan Germany. showed an intusussception at jejunojejunostomy which was reduced at laparoscopy and a gastrostomy done. The third presented on 3rd Background: According to the growing number of bariatric post operative day and had a bolus obstruction due to a kink at operations we are facing a growing number of patients in need of a jejuno-jejunostomy which was corrected at laparoscopy. The fourth revisionary operation. presented two week later; CT confirmed the diagnosis. The kink at Methods: The revisionary operations after bariatric surgery Jejuno-jejunostomy was corrected and a percutaneous gastrostomy performed in the University of Freiburg between 2007 and 2009 were performed at laparoscopy. The gastrostomy tube was left in-situ for analysed regarding indications and outcome. Revisions due to poor six weeks. All patients had an uneventful recovery. weight loss were divided into restrictive and malabsorptive revisions Conclusion: Acute gastric remnant dilatation is mostly due to afferent and weight loss in both groups was compared. loop obstruction. High degree of suspicion and CT imaging will Results: 107 reoperations were performed. Indications were: 11 early confirm diagnosis and could be easily managed by CT guided postoperative revisions (insuffiency of suture lines: 5, abscess: 3, drainage. hernias: 3); 7 late revisions due to surgical complications (stenosis: 2, abdominal pain: 1, hernia: 3, fistula: 1); 25 late revisions due to implant-related complications (band dislocation: 9, stenosis: 8, port P-076 Bariatric Surgery Candidates: Severity and Complexity of related problems: 7, infection: 1); 64 late revisions due to metabolic Mental Health Status complications (aggravation of diabetes: 1, poor weight control: 57, dumping syndrome: 2, malabsorption syndrome: 4). Most revisions PRESENTER: Magdalena Teodorescu (The Ohio State were done because of poor weight loss or weight regain. Patients University Hospital) after malabsorptive reoperations (n=24) showed a significantly better weight loss than patients after restrictive reoperations (n=33). Co-authors: Douglas Kramer1, Bradley Needleman1, Dara P. Conclusion: Most reoperations were done because of poor weight Schuster1 control. This means that the bariatric surgeon must have good knowledge in diagnostics and selection of the appropriate revisionary

operation in these cases. In general malabsorptive revisions show 1. Surgery, The Ohio State University Hospital, Columbus, OH, better results in terms of weight control, but also have more adverse United States. side effects. Also common indications are implant-related problems, the surgeon should also be familiar with the treatment of those. Background: Previous studies have described higher rates of mood disorders, anxiety, and personality disorders in obese patients compared to the general population. The objective of this study is to P-078 The Search For Factors That Might Influence Weight Loss analyze the psychological profile of obese patients considering After Laparoscopic Roux-en-Y Gastric Bypass (LRYGB): bariatric surgery and to investigate possible associations between Insulin-Resistance. these profiles and the severity of their medical conditions. Methods: We performed a retrospective analysis of psychological profiles, including Axis I-IV prevalence, of 285 bariatric surgery PRESENTER: Gil Faria (Hospital Sao Joao) candidates who were evaluated in a large academic center 2007-2009. Co-authors: John R. Preto1, Antonio Gouveia1, Jose Barbosa2, Chi-square analysis was applied between mental health disorders and Silvestre Carneiro2, Eduardo L. Costa1, Cristina Teixeira1, Cidalia severe illness. Gil1, Joaquim Sousa-Rodrigues1, Joaquim Oliveira Alves1 Results: In this population, 61.4% had one, 26.3% had two, 12.9% had three, and 2.9% had four Axis I diagnoses. The most frequent Axis I diagnosis was Major Depression (70.4%), followed by anxiety 1. Unidade Tratamento Cirúrgico de Obesidade - Serviço de Cirurgia disorders (24.5%), Eating Disorder NOS (16.5%), and Attention Geral, Hospital Sao Joao, Porto, Portugal. Deficit Hyperactivity Disorder (12.2%). The most significant Axis II 2. Cirurgia Geral, Faculdade de Medicina do Porto, Porto, Portugal. diagnoses were personality disorders (5.6%). Study subjects reported at least one (90.9%), two (82.5%), three (69.1%), and four (57.5%) Background: Obesity is strongly associated with insulin-resistance Axis III diagnoses. Hypertension occurred with the highest rate and hyper-insulinemia. After surgery, insulin-resistance improves (66%), followed by osteoarthritis (53%), hyperlipidemia (49.8%), significantly and some reports suggest that insulin-resistance might diabetes (44.2%), and sleep apnea (40%). Psychological stressors be related to less weight loss after obesity surgery. included occupational disability (23.8%), problems related to social Methods: Retrospective analysis of the clinical records of 47 environment (20.7%), and problems related to primary support group consectuive patients with more than 6 months of follow-up. We (18.2). Major Depression was associated with severe illness, defined stratified the patients according to the median value of HOMA-IR: as more than 3 medical conditions (p=0.001). 2,45. Outcomes were analyzed at 6 and 12 months post-operatively. Conclusion: The severity and complexity of the physical and mental Results: We analyzed 43 females and 4 male patients (mean age – 37 health status is undermanaged in the bariatric surgery candidates. years ). The mean pre-op weight was 121,7kg (mean BMI of 45,9 Developing an aggressive physical and mental health management kg/m^2). The mean HOMA-IR was 2,54±1,24. BMI at baseline was strategy may improve the long-term success of bariatric surgery. 47kg/m^2 for patients with lower HOMA-IR and 45kg/m^2 for patients with higher HOMA-IR (p=0,04). At 12 months post-op, the rate of ―cure‖ from obesity (BMI<30) was 1 1 2 76,5% vs 23,5%, respectively for lower and higher HOMA-IR Co-authors: John R. Preto , Antonio Gouveia , Jose Barbosa , Silvestre Carneiro2, Eduardo L. Costa1, Cristina Teixeira1, Cidalia (p=0,02). The % of excess BMI lost (%EBL) at 6 months was 62% vs 1 1 1 58%, respectively for lower and higher HOMA-IR (p=0,39). At 12 Gil , Joaquim Sousa-Rodrigues , Joaquim Oliveira Alves months, the %EBL was 84% and 70% (p=0,03). The average total weight lost was not different between groups. 1. Unidade Tratamento Cirúrgico de Obesidade - Serviço de Cirurgia A correlation between HOMA-IR and weight lost could not be Geral, Hospital Sao Joao, Porto, Portugal. established. 2. Cirurgia Geral, Faculdade de Medicina do Porto, Porto, Portugal. Conclusion: Patients with low insulin-resistance, as measured by HOMA-IR appear to have less severe obesity (lower BMI at baseline) Background: HbA1c is proportional to average blood glucose and achieve better overall results in %EBL. However, the inclusion concentration over the previous weeks to months and thus a marker of patients with overt clinical T2DM, might bias these results, as the of long-term glycemic control. It‘s use has been widely accepted to HOMA-IR index was lower in these patients than in patients with monitor glucose balance of T2DM patients. To our knowledge, it impaired glucose metabolism. Larger studies will be necessary to hasn‘t been studied in unselected patients nor it‘s relation to weight confirm and understand these results. loss after surgery. Methods: Retrospective analysis of the clinical records of 47 consectuive patients with more than 6 months of follow-up. We P-079 Portomesenteric Venous Thrombosis With Jejunal stratified the patients according to the median value of HbA1c: 5,5. Ischemia And Spontaneus Splenic Rupture After Laparoscopic Outcomes were analyzed at 6 and 12 months post-operatively. Sleeve Gastrectomy. Two Cases Report And Review Of The Results: We analyzed 43 females and 4 male patients (mean age – 37 Literature years ). The mean pre-op weight was 121,7kg (mean BMI of 45,9 kg/m^2). The mean HbA1c was 5,73±0,79. Age, initial weight and PRESENTER: Juan Contreras (Clinica Santa Maria) BMI were not different between groups. The results of weight loss were similar between groups at 6 months. Co-authors: Ismael A. Court1, Jorge Bravo1, Diva Villao1 At 12 months post-op, the rate of ―cure‖ from obesity (BMI<30) was 93% vs 23%, respectively for lower and higher HbA1c (p=0,001). 1. Surgery and Bariatric, Clinica Santa Maria, Santiago, D.F., Chile. The % of excess BMI lost (%EBL) at 12 months was, respectively 89% and 68% (p=0,003) for the patients with lower and higher HbA1c. The average weight lost at 12 months was 48kg and 38kg Background: Portomesenteric Venous Thrombosis (PVT) after (p=0,02). The BMI achieved at 12 months was of 27,6kg/m^2 and Laparoscopic Sleeve Gastrectomy (LSG) is an uncommon 32,0kg/m^2 respectively for patients with lower and higher HbA1c complication. There are to our knowledge few literature reports that (p=0,006). The Spearman correlation between HbA1c level and try to explain the reasons and management of this potentially lethal (%EBL) at 12 months revealed a coefficient of -0,594 (p=0,001). condition. We report two cases of PVT after LSG. Methods: Case report Conclusion: In unselected patients, and including patients without Results: Case 1: clinical impairment of glucose metabolism, the HbA1c levels A 43-year-old male, 17 days status post LSG was admitted to the negatively correlate with lost weight at 1 year post-op. From our emergency room with new onset of abdominal pain, vomiting and preliminary results, appears that the lower is the HbA1c pre-op, the tachycardia. A CT scan revealed recent appearance thrombosis that better will be the results concerning weight loss. Larger studies will occupies the lumen of portal and splenic vein and the entire superior be necessary to confirm and understand these results. mesenteric vein, with ischemic changes of the Small Intestine. A diagnostic laparotomy was performed that showed necrosis of 130 cm of jejunum. A resection was performed. Anticoagulation therapy P-081 Outcomes Of Laparoscopic Gastric Bypass In The Super was included. The recovery was uneventful. The postoperative study Obese Patients - A Single U.K. Centre Experience revealed Protein C deficiency. Case 2: A 60-year-old female, 7 days status post LSG was admitted to the PRESENTER: Kesava Reddy Mannur (Homerton University emergency room at with new onset of abdominal pain, tachycardia Hospital NHS Foundation Trust) and hypotension. The patient was stabilized hemodynamically. A CT 1 1 1 scan revealed massive hemoperitoneum and thrombosis of the entire Co-authors: Samrat Mukherjee , Kalpana Devalia , Adam Goralczyk portal and splenic vein. A diagnostic laparotomy was performed that showed spontaneous splenic rupture with secondary 1. Bariatric Surgery, Homerton University Hospital NHS Foundation hemoperitoneum. A splenectomy was performed. Anticoagulation Trust, London, United Kingdom. therapy was included. The recovery was uneventful. Conclusion: PVT after LSG is a serious complication. Manifestations Background: The surgical treatment of morbidly obese patients with can include abdominal pain and hemodynamic instability. CT scan a BMI ≥ 50 Kg/m2 (super obese) with significant co-morbidities can provide the diagnosis. Bowel ischemia or spontaneous splenic remains a challenge. We evaluate our outcomes following rupture with hemoperitoneum can be secondary complications. laparoscopic gastric bypass (RYGB) in these patients. Treatment should be individualized. Increased intra-abdominal Methods: We identified all patients (BMI≥50 Kg/m2) who underwent pressure, venous stasis, intraoperative manipulation with endothelium RYGB from 2006 to 2009, from our prospectively maintained damage, and systemic thrombophilic conditions, could be among the database. Patient demographics and co-morbidities were noted and possible etiologic factors. we analysed the morbidity and length of stay. Weight loss following the procedure was tracked and any long term complications noted. Results: 173 patients with BMI ≥ 50 kg/m2 (median 54, range 50 – 95.7) underwent a laparoscopic RYGB for obesity during this period. P-080 The Search For Factors That Might Influence Weight Loss The median age was 44 (range 19 – 69) years and Male:Female = 1:5. After LRYGB: Glycosilated Haemoglobin (HbA1c). Co-morbidities of diabetes, hypertension and obstructive sleep apnoea (OSA) were present in different combinations in 93 patients PRESENTER: Gil Faria (Hospital Sao Joao) (53.8%). All the procedures were completed laparoscopically. The median length of stay was 3 (Interquartile range (IQR) 2 – 4) days. Complications occurred in 17 patients (9.8%) and 5 patients needed 1. Surgery, The Ohio State University Hospital, Columbus, OH, re-laparoscopy. There was no mortality. Of these 3 were revision United States. surgeries following removal of a gastric band. Median weight loss at 1 year was 56.6% of the excess weight (EWL) Background: Mental health disorders can have a negative impact on (IQR 45.3; 68.1). The median %EWL at 2 years was 63.2 (IQR 51.9; weight loss success. However, a psychological profile that predicts 73.4). weight loss failure has not yet been identified. The objective of this Conclusion: With operator experience, RYGB can now be performed clinical study is to develop a psychological profile that can help in the super-obese with low morbidity and effective results. predict preoperatively weight loss success or failure after bariatric surgery. Methods: We performed a retrospective analysis of the psychological profiles of 83 bariatric surgery candidates who were seen in a large academic center 2007-2009. Chi square and independent T test P-082 Decrease in Inflammatory State and Insulin-resistance 6 statistical analyses were applied between the bariatric outcome and to 12 months after Laparoscopic Roux-en-Y Gastric Bypass mental health disorder, and the bariatric outcome and the number of (LRYGB) Axis I diagnoses respectively. Results: Out of 83 bariatric subjects, 71% had a successful bariatric PRESENTER: Gil Faria (Hospital Sao Joao) outcome, defined as weight loss of 30% excess body weight at six- months. Study groups included weight loss success (group 1, n=59) Co-authors: John R. Preto1, Antonio Gouveia1, Jose Barbosa2, and weight loss failure (group 2, n=24). The frequencies of Axis I Silvestre Carneiro2, Eduardo L. Costa1, Cristina Teixeira1, Cidalia diagnoses in group 2 included Major Depression (33.3%), ADHD Gil1, Joaquim Sousa-Rodrigues1, Joaquim Oliveira Alves1 (12.5%), anxiety disorders (12.5%), and Eating Disorder NOS (4%). A similar Axis I profile was seen in group 1, except for ADHD which

had the second highest rate. Axis II diagnoses (personality disorders) 1. Unidade Tratamento Cirúrgico de Obesidade - Serviço de Cirurgia were seen in 8.4% of group 1 and 4.1% of group 2. Problems related Geral, Hospital Sao Joao, Porto, Portugal. to the primary support group were the most prevalent stressor 2. Cirurgia Geral, Faculdade de Medicina do Porto, Porto, Portugal. (12.5%) in group 2, followed by occupational stressors (4.1%) and problems related to social environment (4.1%). Background: Several studies have reported that obesity is related Conclusion: Weight loss failure at six months was not associated with an increase both in inflammatory state and insulin-resistance. with any mental health disorder or the number of Axis I diagnoses Obesity surgery seems to improve both these metabolic parameters. (p=0.503). Short-term response to bariatric surgery is not affected by Our aim is to report these improvements in a series of consecutively the complexity of the psychiatric illnesses as defined by the number operated patients. of the psychiatric diagnoses. Whether the baseline psychological Methods: Retrospective analysis of the clinical records of 47 profile has an impact for long-term weight-loss success is unclear. consectuive patients with more than 6 months of follow-up. We compared the central tendency and dispersion measures of the results pre-operatively and 6-12 months after surgery. P-084 Methods Of Closure Of Common Enterotomy Of The Results: We analyzed 43 females and 4 male patients (mean age – 37 Jejunojejunostomy Affects Alimentary Limb Narrowing During years ). The mean pre-op weight was 121,7kg (mean BMI of 45,9 Gastric Bypass Surgery. kg/m^2).

The mean CRP pre-operatively was 10,31mg/L±7,71, and only 8,6% PRESENTER: Meena Theva (Boston Medical Center) of patients had a ―normal‖CRP value (<3mg/L). There were no differences in CRP levels according to BMI, age or HOMA-IR index. Co-authors: Miguel Burch2, Brian Carmine1, Donald Hess1 Six months to 1 year after surgery, the mean CRP value was 1,21mg/L±1,22 and 89,5% of patients achieved CRP<3mg/L. The paired samples analysis revealed a significance at p<0,001 level. This 1. Boston Medical Center, Boston, MA, United States. reduction in CRP was independent of weight loss (no correlations 2. Cedar Sinai, Los Angeles, MA, United States. found). The mean HOMA-IR pre-operatively was 2,54±1,24. There were no Background: In a porcine animal model, we compared the two differences in HOMA-IR index according to BMI, age or CRP levels. common methods of constructing a jejejunojejunostomy by either the Six months to 1 year after surgery, the mean HOMA-IR index was bidirectional triple stapling method (TSM) or the single staple line 0,83±0,4. The paired samples analysis revealed a significance at double stapling method (DSM). We hypothesize that the TSM will p<0,001 level. This reduction in HOMA-IR was independent of result in the least narrowing of the alimentary limb because of the weight loss (no correlations found). central closure of the common enterotomy site. Conclusion: According to these preliminary results, after LRYGB Methods: Under IACUC approval, a porcine model was used to patients had significant reductions both in inflammatory state and construct two types of roux-en-Y jejunojejunostomies: single staple insulin-resistance markers, independently of lost weight. These line with end common enterotomy closure (double stapler method - reductions might be connected with the overall reduction in DSM) and bidirectional staple line with central common enterotomy morbidity and mortality from all causes in these patients. closure (triple stapler method -TSM). The ends of the bowel were filled with Polyurethane self-curing foam (GREATSTUFF ™ - DOW Chemicals) until all limbs and anastomosis were distended. The P-083 Predicting bariatric surgery outcomes based on samples were measured to assess the degree of narrowing in the two psychological and behavioral status methods. Results: See tables below. PRESENTER: Magdalena Teodorescu (The Ohio State Conclusion: This study provides experimental data to support the University Hospital) theory that the TSM results in less narrowing of the alimentary limb. Although statistically significant, the next step of this research is to Co-authors: Douglas Kramer1, Bradley Needleman1, Dara P. measure flow of chyme through the anastomosis to further validate Schuster1 this hypothesis. Kingdom.

Background: The pre-sternal access port for gastric bands is usually Mean Anastomosis Diam (cm) placed through a transverse incision. This can be technically tiresome DSM 12.5547 and is associated with poor cosmesis. In January 2007 we introduced a scarless-sutureless technique in which the access port is placed in a TSM 13.5819 pre-sternal subcutaneous pocket, tunnelled up from the epigastric port T-Test 0.0690258 site. The access port is not sutured in and subsequent band fills are routinely performed without the need for fluoroscopy.

Methods: A prospective database of all bariatric procedures was analysed from January 2007 to date. Patients underwent gastric Mean Alimentary Mean Alimentary banding via the pars flaccida approach. A gastric band with low- T-Test Diam (cm) Narrow Diam (cm) profile port system was used (AMI, Austria). DSM 7.302684615 6.72774 *0.03041141 Results: Two hundred and sixty-four patients underwent gastric banding using the scarless-sutureless port technique (80% female). TSM 6.949722222 7.1943 0.27228963 This technique reduced operating time by 10 minutes (55mins v 45 minutes, p<0.01 Mann Whitney U). With up to 3 years of follow-up,

most patients (>96%) have experienced trouble-free band P-085 Evidence That The United Kingdom Shares A Similar adjustments with only ten (3.8%) requiring subsequent fixation of the Metabolic Syndrome Epidemic To The United States access port to the pre-sternal fascia due to difficulty in accessing the port and/or port rotation. PRESENTER: Conor Magee (Gravitas Centre for Bariatric Conclusion: The scarless-sutureless access port technique is safe and Surgery) gives excellent cosmetic results. It reduces operating time and in the vast majority of cases allows trouble-free band adjustment. Co-authors: Jayne M. Brocklehurst1, Simon Weaver1, Shafiq Javed1, 1 1 Fluoroscopic band adjustments are not routinely required. We Robert Macadam , David Kerrigan recommend the use of this technique to other groups.

1. Gravitas Centre for Bariatric Surgery, Liverpool, 0, United Kingdom. P-087 Long Term Results Of Roux-En-Y Gastric Bypass After Failed Laparoscopic Vertical Banded Gastroplasty In 17patients. Background: The incidence of Metabolic syndrome (MetS) is increasing in the USA (Varel reported 27.4% in the morbidly obese). PRESENTER: Konstantinos Arapis (Hôpital Bichat) Is the UK experiencing a similar epidemic? Methods: Prospective bariatric surgery database. MetS identified Co-authors: Denis Chosidow1, Pierre Fournier1, Lara Ribeiro- using International Diabetes Federation criteria (BMI>30 plus two or Parmenti1, Jean Pierre Marmuse1 more of : Type 2 diabetes, Hypertension, Dyslipidaemia and Hypercholesterolaemia). Data analysed using Mann-Whitney U and 1. Surgery, Hôpital Bichat, Paris, France. Chi squared tests.

Results: Between 2007 and 2009, 120/492 patients treated (24%) met Background: Vertical banded gastroplasty (VBG) has recently been the criteria for MetS ), 40% of whom had all five criteria. Seventy replaced by other bariatric procedures. Still, morbidely obese patients four percent of patients with the metabolic syndrome had type 2 with a failed VBG, continue to seek for treatment of their disease. diabetes. Patients with metabolic syndrome were older (median age The aim of our study was to evaluate the long-term results of 50 v 44, p<0.001) and more likely to be from the publicly funded laparoscopic Roux-en-Y gastric bypass (LRYBP) as a revision NHS than self-funding (32% vs 15%, p<0.001). Although NHS procedure after VGB in our department patients were heavier than private patients (median BMI 50 v 43.8, Methods: Seventeen patients (2 males and 15 females) underwent p<0.001), this is unlikely to explain the observed differences in the LAGB after a failed VGB. Median time between the VGB and incidence of the metabolic syndrome, as mean BMI in those with and LAGB was 65 months (SD: 12,3). The indications for a revision without the condition was similar (BMI 47 v 47.8, p=0.07). were: disruption of the staple line (n = 4), overenlargement of the Conclusion: Metabolic syndrome is common in UK patients referred gastric pouch (n = 2), inefficient stoma (n = 2) and insufficient for bariatric surgery, with an incidence similar to that of patients from weight loss (n=9). Preoperatively median body mass index (BMI) the USA. These patients tend to be older, but not heavier than those was 42,3 (SD: 4,6). A standard LRYGB was performed in all cases. without MetS. NHS patients have an over-representation of MetS, but Results: Perioperative morbidity rate was 15%, while no mortality this may reflect referral criteria and socio-economic differences. was encountered. Median follow up was 35 months (SD: 3,5). During Bariatric surgeons should be aware of the presence of metabolic follow-up 2 patients developed complications. At 2 and 5 years syndrome in their patients. Further work regarding the best procedure postoperatively median BMI was 34 kg/m2 and 32kg/m2 respectively for metabolic syndrome needs to be performed. while median percentage of excess weight loss (%EWL) was 42,3% (SD 12,4) and 49,5% (SD: 14,4%) respectively Conclusion: LRYGBP is a safe and efficient means of revision after P-086 The Scarless-Sutureless Technique for Gastric Band failed VBG with durable results and could be considered the Access Port Placement- Results at Three Years procedure of choice for such complex cases

PRESENTER: Conor Magee (Gravitas Centre for Bariatric Surgery) P-088 An Enhanced Recovery Protocol For Patients Undergoing Laparoscopic Roux-En-Y Gastric Bypasses Co-authors: Jayne M. Brocklehurst1, Simon Weaver1, Robert Macadam1, Shafiq Javed1, David Kerrigan1 PRESENTER: Kamal Mahawar (Sunderland Royal Hospital)

1. Gravitas Centre for Bariatric Surgery, Liverpool, 0, United Co-authors: Maureen Boyle2, Shlokarth Balupuri1, Peter K. Small1 surgery was performed laparoscopically. Post-operative mortality and 1. Department of General Surgery, Sunderland Royal Hospital, incidence of symptomatic venous thromboembolism was zero. Sunderland, Tyne and Wear, United Kingdom. Conclusion: Careful selection of patients for gastric banding with 2. Department of Dietetics, Sunderland Royal Hospital, Sunderland, robust follow-up of patients avoiding an overtight band can result in a Tyne and Wear, United Kingdom. low incidence of band complications requiring subsequent revisional surgery. Background: We adopted an enhanced recovery protocol for laparoscopic roux-en-Y gastric bypass (LRYGB) patients in April‘ 2009. This study summarizes our initial experience with this P-090 Body Image Misperception May Influence Progression To protocol. Super-Obesity Methods: A total of 110 LRYGB patients have gone through this protocol to date. Patients were admitted day before surgery and PRESENTER: Conor Magee (Gravitas Centre for Bariatric commenced on 40 mg Enoxaparin and compression stockings. Whilst Surgery) in theatre, intermittent compression devices were used. All operations were successfully completed laparoscopically. Methylene blue was Co-authors: Jayne M. Brocklehurst1, Simon Weaver1, Robert used to test the gastrojejunal anastomosis intraoperatively. Macadam1, Shafiq Javed1, David Kerrigan1 Nasogastric or orogastric tubes were routinely removed at the end of the operation and no drains were used. Patients were returned to the 1. Gravitas Centre for Bariatric Surgery, Liverpool, 0, United surgical ward from theatre recovery and early ambulation was Kingdom. encouraged by a team of dedicated nursing staff. Patients were allowed sips immediately, up to 1.0 litre of clear fluid on day 1 and Background: We investigated body image perception in patients commenced on soft diet on day 2 in conjunction with specialist undergoing bariatric surgery and whether altered body perception dietetic input. Patients were allowed home on day 2 as a matter of differs between the super-obese (BMI >50) and lighter patients (BMI routine except if it was a holiday when they were discharged on day 35-50). 3. Data regarding these patients were obtained from a prospectively Methods: A questionnaire using modified Stunkard silhouettes of maintained database. male and female body shapes representing BMIs from <19 to >50 Results: Mean hospital stay was 3.9 days (Median-4, Range 3-10). was prospectively administered to patients requesting bariatric There was no mortality and no anastomotic leak. One patient required surgery. Patients were asked to identify their current body image, and reoperation for bleeding from short gastric vessels on the same day. also their ideal and acceptable body image following bariatric This was our only 30 day reoperation. Three patients required surgery. Data were analysed using the Chi square test, postoperative blood transfusion. 30 day readmission rate was 1.9%. Results: Of 112 patients (81% female), half couldn‘t correctly Conclusion: Enhanced recovery is safe for patients undergoing identify their current body shape (BMI <50, 29%; super obese 77%, laparoscopic roux-en-Y gastric bypasses. p<0.01). Of those patients who misidentified their current shape, 97% of lighter patients (BMI <50) over-estimated their true size, whereas the reverse was true for the super-obese, every one of whom under- P-089 Careful Patient Selection And Follow-Up May Be The Key estimated their body image (p<0.001). To Low Rates Of Gastric Band Revision Reassuringly, the majority of patients had realistic expectations of what weight loss surgery can deliver, although a third aspired to a PRESENTER: Conor Magee (Gravitas Centre for Bariatric normal BMI silhouette (something weight loss surgery rarely Surgery) delivers) and a worrying 5% (with a median BMI of 51.3kgm-2) chose an ideal outcome that was actually underweight. Co-authors: Jayne M. Brocklehurst1, Simon Weaver1, Robert 1 1 1 Conclusion: Body image misperception is common in patients Macadam , Shafiq Javed , David Kerrigan seeking bariatric surgery, particularly in those with a BMI >50. Super-obesity seems to represent a threshold that once crossed is 1. Gravitas Centre for Bariatric Surgery, Liverpool, 0, United associated with underestimation of true body size (perhaps through Kingdom. denial) and thus potentially to ever-more severe degrees of obesity.

Background: Revision of failed gastric bands (due to erosion/unbuckling/slippage or poor weight loss) has been reported in P-091 The Role Of Crural Repair In Lagb In Morbidly Obese 10% or more. We discourage gastric banding (LAGB) in sweet-eaters Patients With Gastro-Oesophageal Reflux and those who ingest crumbly, high-calorie or meltable foods. This selection, together with robust follow-up protocols designed to avoid PRESENTER: Simon Weaver (Gravitas Bariatric Surgery Ltd) an overtightened band has produced EWL equivalent to gastric bypass at 3 years; but did it reduce band complications and Co-authors: Conor Magee1, Jayne M. Brocklehurst1, Robert subsequent band revision? Macadam1, Shafiq Javed1, David Kerrigan1 Methods: Prospective bariatric database. Inclusions - all patients who underwent primary LAGB using the protocols described above. All 1. Gravitas Bariatric Surgery Ltd, Liverpool, United Kingdom. band complications requiring revisional surgery were identified.

Exclusions - surgery for minor port-site problems. Background: The effect of laparoscopic adjustable gastric banding Results: 354 patients satisfied the inclusion criteria. Revisonal LAGB (LAGB) on GORD symptoms is uncertain, and the benefits of surgery was required in 8 cases (2.3%). Two patients (0.6%) had concurrent hiatal repair unclear. revision because of a failure to lose weight in the absence of a technical band problem (both patients were consumers of high calorie Methods: All patients with pre-operative GORD symptoms who meltable foods, despite attempts at pre-op selection). The other 6 underwent LAGB were intraoperatively assessed for crural laxity via cases involved technical failures (one band erosion [0.3%], two band placement and withdrawal of an intragastric balloon through the slippages [0.6%] and three spontaneous unbucklings [0.9%]). The hiatus (36Fr, 20ml). A concurrent crural repair was performed if this LAGB were revised to gastric bypass (6 cases), sleeve gastrectomy test was positive. Patients were assessed at 3,6 and 12 months via a (one case) and to a different make of band (one case). All revisional modified Visick score (along with requirement for anti-reflux 1 1 1 medication) and compared with those with pre-op GORD symptoms Co-authors: Euan Shearer , David Kerrigan , Carmen A. Lacasia who did not have a crural repair at the time of LAGB Results: Of the patients with symptomatic reflux 18/108 (17%) had a 1. Gravitas Centre for Bariatric Surgery, Liverpool, 0, United positive crural laxity test at the time of LAGB insertion and Kingdom. underwent a concurrent crural repair. There was no sex difference (8/18 male). Eighty nine percent (16/18) had complete resolution of Background: Bariatric patients are often perceived as difficult to symptoms, the majority by the 3rd postoperative month. In contrast intubate and it is common practice to routinely use awake fibre-optic only 13/90 (14%) with operatively diagnosed intact crurae had (F/O) laryngoscopy and intubation. Our experience does not support complete remission of symptoms by 12 months. Mean modified this approach. Viscik scores were 1.17 and 2.26 (p<0.01) respectively at 12 months. Methods: A prospective database of 241 anaesthetic records of There was no significant difference in either group in terms of patients undergoing bariatric anaesthesia under the care of a single %EWL or BMI at 3, 6 or 12 months followup specialist anaesthetist over a 4 year period were studied. Patients Conclusion: Morbidly obese patients with reflux undergoing LAGB were stratified by the difficulty of intubation using the should be assessed for the presence of crural laxity. It is a common Cormack/Lehane score. finding (17% in this series) and subsequent crural repair seems to Results: Awake fibre-optic intubation was required in 2/241 cases give superior resolution of reflux type symptoms. (0.8%), both intubation Grade 3. One patient had severely restricted mouth opening, the other cervical spondylosis. Neither was obesity- related and would present airway management problems in non-obese P-092 Enoxaparin 40 Mg Daily Is Safe And Effective In patients. All others were intubated using a Macintosh laryngoscope Preventing Deep Vein Thrombosis In Patients Undergoing +/- bougie. There were no failed intubations. Bariatric Surgery There was no difference in BMI between intubation groups. Those patients in the grade 3 intubation group were older than those in PRESENTER: Kamal Mahawar (Sunderland Royal Hospital) groups 1 and 2 (p=0.01, Mann Whitney U). Conclusion: BMI alone does not correlate with the difficulty of Co-authors: Maureen Boyle2, Shlokarth Balupuri1, Peter K. Small1 tracheal intubation in patients undergoing elective bariatric surgery, although increasing age may be a factor. The routine use of awake 1. Department of Surgery, Sunderland Royal Hospital, Sunderland, fibre-optic intubation in elective bariatric patients is not indicated and United Kingdom. should be reserved for those patients who are predicted pre- 2. Department of Dietetics, Sunderland Royal Hospital, Sunderland, operatively of having anatomical problems affecting the airway. Tyne and Wear, United Kingdom.

Median Median Background: Bariatric patients are at an increased risk of developing Intubation Male:Female F/O N Age BMI deep vein thrombosis in the postoperative period. A variety of Grade Ratio intubation (Range) (Range) strategies have been reported in literature to deal with this problem, 43.3 yrs 53.3 some of which employ higher doses of low molecular weight heparin 1 192 49:143 0 or a prolonged duration of use postoperatively or both. This study (20-64) (32-89) reports our experience with standard dose 40 mg Enoxaparin in 46.2 yrs 53.0 2 39 15:24 0 conjunction with class I compression stockings, intermittent (30-64) (38-68) compression devices and early mobilization in preventing deep vein 51.6 yrs 54.1 thrombosis. 3 10 5:5 2 Methods: Data regarding 762 consecutive bariatric procedures (236 (44-72) (43-85) laparoscopic gastric bypasses, 520 laparoscopic gastric bands, and 6 sleeve gastrectomies ) were obtained from a prospectively maintained database. All patients received 40mg of Enoxaparin daily which was P-094 Careful Patient Selection And Follow-Up May Be The Key started preoperatively and continued postoperatively until discharge To Low Rates Of Gastric Band Revision from the hospital. Patients were fitted with elastic compression stockings preoperatively and started on pneumatic intermittent compression devices whilst in theatre. Compression devices were PRESENTER: Conor Magee (Gravitas Centre for Bariatric Surgery) continued on the ward until patients were fully mobile. A policy of Co-authors: Jayne M. Brocklehurst1, Simon Weaver1, Robert early mobilization and ambulation was adopted with the help of a 1 1 1 team of committed nursing staff and a motivated educated patient. Macadam , Shafiq Javed , David Kerrigan Results: No patient in this series developed clinical deep vein thrombosis or pulmonary embolism. Two of our bypass patients 1. Gravitas Centre for Bariatric Surgery, Liverpool, 0, United required reoperation and a further seven required blood transfusion Kingdom. before discharge. None of the gastric banding patients required blood transfusion or reoperation before discharge. Background: Revision of failed gastric bands (due to Conclusion: 40 mg Enoxaparin daily, started preoperatively, in erosion/unbuckling/slippage or poor weight loss) has been reported in conjunction with other strategies, is effective in preventing deep vein 10% or more. We discourage gastric banding (LAGB) in sweet-eaters thrombosis and pulmonary embolism in patients undergoing bariatric and those who ingest crumbly, high-calorie or meltable foods. This surgery. selection, together with robust follow-up protocols designed to avoid an overtightened band has produced EWL equivalent to gastric bypass at 3 years; but did it reduce band complications and P-093 Routine Awake Fibre-Optic Intubation Is Not Required subsequent band revision? For Bariatric Patients Methods: Prospective bariatric database. Inclusions - all patients who underwent primary LAGB using the protocols described above. All PRESENTER: Conor Magee (Gravitas Centre for Bariatric band complications requiring revisional surgery were identified. Surgery) Exclusions - surgery for minor port-site problems. Results: 354 patients satisfied the inclusion criteria. Revisonal LAGB ulceration was a common finding after gastro-jejunal anastomosis but surgery was required in 8 cases (2.3%). Two patients (0.6%) had is this true in the days of potent acid suppression therapy? We audited revision because of a failure to lose weight in the absence of a our results of LRYGB over an 8 year period to ascertain the technical band problem (both patients were consumers of high calorie incidence of marginal ulceration. meltable foods, despite attempts at pre-op selection). The other 6 Methods: A prospective database of patients undergoing bariatric cases involved technical failures (one band erosion [0.3%], two band surgery was analysed. Pre-operative upper gastrointestinal endoscopy slippages [0.6%] and three spontaneous unbucklings [0.9%]). The and Helicobacter testing were not routinely undertaken. A lesser LAGB were revised to gastric bypass (6 cases), sleeve gastrectomy curve based gastric pouch technique was introduced in 2007. Patients (one case) and to a different make of band (one case). All revisional received a 3-month course of oral proton pump inhibitor therapy surgery was performed laparoscopically. Post-operative mortality and following surgery. Endoscopy was only performed as part of the incidence of symptomatic venous thromboembolism was zero. investigation for post-operative upper gastro-intestinal symptoms. Conclusion: Careful selection of patients for gastric banding with Results: 571 patients were identified. Marginal ulceration was robust follow-up of patients avoiding an overtight band can result in a diagnosed in two cases (0.3%). Both patients had been taking low incidence of band complications requiring subsequent revisional NSAIDS. These patients did not have a lesser curve based gastric surgery. pouch. Gastrojejunal stenosis was much more common (6.3%). Conclusion: Marginal ulceration is uncommon following LRYGB. The low incidence of marginal ulceration may reflect the post- P-095 Is Routine “Group And Save” Necessary Before operative use of proton pump inhibitors and possibly the introduction Laparoscopic Gastric Banding And Roux-En-Y Gastric Bypass? of the lesser curve based gastric pouch. However, all causes of upper abdominal pain after LRYGB require investigating and surgeons PRESENTER: Kamal Mahawar (Sunderland Royal Hospital) should keep an open mind regarding the causes of post-operative pain. Co-authors: Samuel Parker1, Shlokarth Balupuri1, Peter K. Small1

1. Department of Surgery, Sunderland Royal Hospital, Sunderland, P-097 How Does A Low Carbohydrate Preoperative Diet Impact United Kingdom. On The Accuracy Of Results Of Bariatric Surgery?

PRESENTER: Simon Weaver (Gravitas Bariatric Surgery Ltd) Background: An ever increasing number of bariatric procedures are being carried out in our hospital. Current local guidelines require all Co-authors: Jayne M. Brocklehurst1, Conor Magee1, Robert patients undergoing laparoscopic gastric banding or laparoscopic Macadam1, Shafiq Javed1, David Kerrigan1 roux-en-Y gastric bypasses to have blood grouped and saved as part of their pre-operative assessment. The purpose of this study was to find out blood transfusion requirements of these patients with a view 1. Gravitas Bariatric Surgery Ltd, Liverpool, United Kingdom. to examine our current practice of routinely grouping and saving blood for them. Background: Morbidly obese patients often have non-alcoholic fatty Methods: The hospital database was retrospectively examined to find liver disease and consequent hepatomegaly which can make proposed out blood transfusion requirement for each of the 520 laparoscopic bariatric surgery more complicated. A preoperative low carbohydrate gastric bands and 236 laparoscopic gastric bypasses patients carried diet has been championed as the solution, with studies confirming out in our centre till date. Each patient had two blood samples taken reduction of liver size. It is not clear from the literature whether diet- for group and save, one at the time of pre-anaesthetic check up and induced pre-surgical weight loss skews the interpretation of the second on admission for surgery. results of surgical intervention. Results: Seven out of 236 (3%) gastric bypass patients needed blood Methods: All patients who had bariatric surgery were asked to transfusion prior to discharge from the hospital. None of the 520 complete a carbohydrate restricted diet for 2 weeks prior to surgery. gastric bands required blood transfusion in the immediate Weight, height and BMI was measured at the initial consultation and postoperative period. on the day of surgery. All patients had surgery within 6 weeks of the Conclusion: There is a need to review routine group and save policy initial consultation. for laparoscopic gastric banding patients. This has significant Results: In total 591 patients were studied – 330 patients (56%) lost implications for limited health care resources. We however feel a weight on the pre-op diet (median weight loss 4.2kg, range 0.6 to continued need to routinely group and save blood for laparoscopic 19.6 kg), whereas 140 patients remained static and 121 actually roux-en-Y gastric bypass patients. gained weight (median gain 3kg, range 0.5 to 13.7kg). In calculating 1-year %EWL, if the initial outpatient assessment weight was used rather than weight on the day of surgery, a potential P-096 Marginal Ulceration Is A Rare Event Following overestimate of excess weight loss would occur in 56% and an Laparoscopic Roux-En-Y Gastric Bypass (Lrygb) underestimate in 20% (121/591). This could skew the results of ‗surgically-induced‘ weight loss significantly PRESENTER: Conor Magee (Gravitas Centre for Bariatric Conclusion: We recommend reporting of %EWL results should be Surgery) standardised to reflect operative weight and BMI on the day of surgery to exclude the confounding influence of preoperative weight Co-authors: Jayne M. Brocklehurst1, Simon Weaver1, Robert loss induced by the ‗liver-shrinking‘ low carbohydrate diet. Macadam1, Shafiq Javed1, David Kerrigan1

1. Gravitas Centre for Bariatric Surgery, Liverpool, 0, United Kingdom. P-098 Prevalence, Management And Outcomes Of Staple Line Dehiscence After Laparoscopic Sleeve Gastrectomy For Morbid Obesity. Background: Marginal ulceration following LRYGB is a recognised complication; however the true incidence and significance of this condition remains to be established. Historically, gastro-jejunal PRESENTER: Michael McClure (Cleveland Clinic Florida) Co-authors: Jayne Lieb1, Samuel Szomstein 1, Raul J. Rosenthal 1 endoscopy has also been described. Post-operative anastomotic leaks can be treated by drainage, endoscopic stenting and /or resuturing but 1. Cleveland Clinic Florida, Weston, FL, United States. delays discharge from hospital. Persistent intra-operative leak in spite of resuturing and revision is a challenging problem as over-suturing of anastomosis can lead to ischemia and stenosis. Primary stenting at Background: With the increase in the number of laparoscopic sleeve index surgery successfully treated our patient with persistent intra- gastrectomies (LSG) being performed, the incidence of complications operative leak. are also bound to increase. The most feared complication is a stapled line dehiscence (SLD). We discuss the prevalence, diagnosis and management of this complication. P-100 Laparoscopic Fundoplication for Barrett’s Esophagus Methods: After IRB approval,the records of patients that underwent After Roux-en-Y-Gastric Bypass For Obesity LSG between 2004 and 2009 were retrospectively analyzed from a prospectively collected database. Results: In 4 cases a staple line dehiscence was recorded. Two of the PRESENTER: Nilton Kawahara (University of Sao Paulo School patients had there primary operations performed at our institution of Medicine) (0.47%) and two were transferred from outside facilities. Three Co-auithors: Clarissa Alster3, Fauze Maluf-Filho 4, Kelvin Higa2, dehiscence‘s were proximal and one was distal. In three cases a SLD 3 occurred after a primary LSG and in another case in a secondary LSG Daniel A. Yamada after removal of an LAGB. All patients required a laparoscopic reoperation. One case had to be converted to an open procedure. Of 1. Surgical Technique, University of Sao Paulo School of Medicine, the proximal SLD, two were managed by laparoscopy and drainage Sao Paulo, Brazil. and one was converted to a Roux en Y gastric bypass. The distal SLD 2. Minimally Invasive and Bariatric Surgery , Fresno Heart & was managed with a t-tube. Surgical Hospital, Fresno, California, USA., Fresno, CA, United Complications included two intraabdominal abscesses that were States. managed with percutaneous drainage and one infected trocar site.. 3. Topographic Anatomy, LIM02, University of Sao Paulo School of There were no complications with the conversion to roux en y gastric Medicine, SP, SP, Brazil. bypass. Length of stay ranged between 9-21 days with the average 4. Gastrointestinal Endoscopy Unit of the Department of being 17 days. There were no mortalities. Gastroenterology, University of Sao Paulo School of Medicine, SP, Conclusion: Staple line dehiscence after LSG is a rare complication SP, Brazil. that requires prompt intervention. Drainage, stenting, and conversion Background: Roux-en-Y-Gastric Bypass (RYGB) has been employed to RYGBP are possible treatment options that vary based on location for treatment of gastroesophageal reflux disease (GERD) as an of the dehiscence. Successful management of these patients can be alternative to fundoplication. Up to 22% of patients who undergo managed laparoscopically in the majority of the cases. successful RYGB operations still develop GERD symptoms postoperatively. Obese women are likely to be a risk factor for Barrett‘s esophagus (BE), independently of GERD. Association P-099 Primary Anastomotic Stenting For Persistent between the development of BE post-esophagectomy was already Intraoperative Leaking Anastomosis During Laparoscopic described but not after RYGB for obesity. Gastric Bypass: A Proactive Approach. Methods: We report management of intractable postoperative reflux o with a modified laparoscopic 360 fundoplication, 6 years after a PRESENTER: Dugal Heath (Whittington Hospital) laparoscopic RYGB operation. Results: A modified post-RYGB fundoplication was made in a 27- Co-authors: Ramar Sasindran1, Pratik A. Sufi1 year-old female (BMI 31), by wrapping the excluded stomach. Conclusion: To our knowledge, it‘s the first case described of 1. Bariatric surgery, Whittington Hospital, London, uk, United abdominal anti-reflux surgery performed by laparoscopy in the late Kingdom. postoperatory of bariatric surgery. It may prove to be a good surgical option for the treatment of BE complications after RYGB operation.

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGB)is effective in achieving weight reduction in obese patients. Leaks at gastro-jejunal anastomosis can be as high as 5% and can be lethal. Methods: AA 46-year old female (BMI 61) with osteoarthritis, infertility, polycystic ovarian syndrome, stress incontinence, chronic obstructive pulmonary disease and asthma underwent a LRYGB. During gastro-jejunostomy, the stomach slipped during staple firing. The anastomosis was completed using intracorporeal 2-0 PDS sutures but a methylene blue test revealed a leak through anterior anastomotic line. There was a persistent small leak despite 2 attempts to resuture and refashioning of the anastomosis. An intra-operative gastroscopy was performed and a covered stent was placed across the gastrojejunal anastomosis (100cm stent with 70cm cover) aided by fluoroscopy. Results: Post-operatively, the patient commenced free fluids on day three after a normal gastrograffin study and was discharged home. The stent was removed 4 weeks later uneventfully.

Conclusion: Prophylactic measures to decrease staple line and Fig 1 – The proposed modified fundoplication post-Roux-en-Y anastomotic leaks include using bio-absorbable reinforcement Gastric Bypass (RYGB): A – Surgical anatomy post-RYGB and pre- materials, application of fibrin sealant and omental patching. fundoplication. B – Surgical Anatomy post-RYGB and post- Intraoperatively, it is common to assess the integrity of anastomosis fundoplication using the excluded stomach. C – Endoscopic findings: and test for leaks with methylene blue and /or pneumatically - grade 3 esophagitis (Savary-Miller) and Los Angeles classification grade C, with 0,8 cm Barrett‘s esophagus. D - Histological P-102 Laparoscopic Sleeve Gastrectomy in HIV-Infected Patients appearance of Barrett‘s epithelium with the presence of specialized (LSG-HIV) For Obesity control cells (intestinal metaplasia and Goblet cells). PRESENTER: Nilton Kawahara (University of Sao Paulo School of Medicine)

Co-authors: Clarissa Alster2, Yuri Nascimento Cardoso de Moraes2

1. Surgical Technique, University of Sao Paulo School of Medicine, Sao Paulo, Brazil. 2. Topographic Anatomy, LIM02, University of Sao Paulo School of Medicine, SP, SP, Brazil.

Background: HIV has now became a chronic disease. Long-term complications related to obesity have gained a new importance especially in HIV-infected patients who currently live longer. In particular, even the use of highly active antiretroviral therapy (HAART) has been associated with body weight gain, multiple Fig 2 – Operative findings and treatment during laparoscopy: A – metabolic problems, such as dyslipidemia, lipodystrophy, insulin The hiatal hiatus was sutured; A 3 cm gastric pouch and the manually resistance, and an increased risk of coronary artery disease. Gastric performed gastrojejunal anastomosis are seen. B –The excluded bypass surgery on HIV-infected patients may not be beneficial to the stomach was dissected and passed behind the esophagus (arrows); all patient‘s disease possibly due to postoperatory less than optimal the vasa breve vessels were ligated; C – a modified 360o weight loss and short-term significant decreased in CD4 count fundoplication was finally performed with three interrupted sutures observations after surgery. with 3.0 polypropylene, totalizing 3 hours of surgery. Methods: We report a 33-year-old asymptomatic HIV-infected and morbidly obese woman (body mass index of 60,3) who underwent a P-101 Demographic Profile of Patients undergoing bariatric successful laparoscopic Sleeve gastrectomy (LSG-HIV) for obesity Surgery at a North London Centre control in 2006. Results: Obesity-related comorbidities (severe liver steatosis, dyslipidemia and arthropaties) and stable HIV infection receiving no PRESENTER: Dugal Heath (Whittington Hospital) HAART were present at surgery. She underwent a successful LSG for obesity control. Follow-up after four years of surgery revealed no Co-authors: Sufi Pratik1, Abigail Smith1, George Pontikis1, Kirsten demonstrated clinically significant deterioration in the CD4 count or McDougall1, Lucy Jones1 immune status, and no progression to acquired immunodeficiency syndrome. The comorbidities resolved and she presented improved 1. Bariatric surgery, Whittington Hospital, London, uk, United lipid profile. She had two pregnancies after LSG. Kingdom. Conclusion: Considering that no effective treatment for obese HIV patients has been devised to date, bariatric surgery may prove to be a Background: Morbid obesity is a growing problem in the UK but viable option. bariatric surgery is only available in a limited number of hospitals in the National Health Service (NHS). The aim of this study is to examine the population undergoing bariatric surgery in a North London NHS hospital. Methods: Data was prospectively collected from patients undergoing laparoscopic gastric band, gastric bypass and sleeve gastrectomy at the Whittington hospital between January 2007 and May 2009. Results: A total of 174 patients (132 female, 42 male) underwent surgery - more women compared with men (76% vs. 24%). The mean age of patient at presentation was 42.8 years, with women on average presenting younger (mean age: 42.5 vs. 43.8). The mean start weight was 135kg (range 84.3-279kg), men weighing more compared to female counterparts (172 vs. 126kg) resulting in a mean excess body weight (EBW) of 68.9kg across the population. A similar trend was observed for body mass index (BMI) - mean 49.3kg/m2 (range 32.9- 81.0kg/m2) - with women on average less obese at presentation (47.5 vs. 56.7 kg/m2). Diabetes (52%), hypertension (47%) and osteoarthritis (34%) were the most prevalent co-morbidities in the female population. In men, the most common co-morbidities were obstructive sleep apnoea (60%), hypertension (41%) and diabetes (38%). Compared to men, women had double the rates of depression (>60%). A third of patients had no co-morbidities. Conclusion: Patients undergoing bariatric surgery in North London are predominantly middle aged females with diabetes and/or hypertension with an approximate EBW of 70kg. The demographic profiles observed here were very similar to other bariatric centres, After dissection of the greater omentum and the short gastric vessels both in the UK and abroad. (1A), the greater curvature is resected along a 34-Fr gastric tube using the Endo-GIA. The remaining gastric sleeve has a volume of about 100 ml (1B). postoperative complications, particularly fistulas: 1.3%, stenosis 0.7%, among others. There were no conversions to open technique and no mortality. At follow-up at 3, 6 and 12 months was observed P0103 Hiatal Hernia and GERD Management in Adjustable percentage loss of excess BMI of 55 ± 20%, 73 ± 25% and 81 ± 29% Gastric Band respectively with statistically significant difference (P <0.01). In the 12 months follow-up to 61.5% referred the remission of diabetes and PRESENTER: Juan Lopez-Corvala (Hospital Angeles Tijuana) 38.5% improved their metabolic condition. Conclusion: Sleeve Gastrectomy is a safe and effective procedure Co-authors: Fernando Guzman-Cordero1, Francisco Ortega-Pallanez1 with little morbidity and zero mortality. Optimal results are evidence as to reduce excess weight in the 12 months follow up. We need more 1. Hospital Angeles Tijuana, San Ysidro , CA, United States. Studies with long-term follow-up to assess the maintenance of these results.

Background: Morbid obesity is an important risk factor in the development of gastroesophageal reflux disease (GERD) and hiatal hernia (HH). Initially, HH and GERD were considered absolute P-105 Revisional Surgery: Conversion From Gastric Banding To Sleeve Gastrectomy In A Single Procedure. contraindications for adjustable gastric band (AGB) placement.

Currently there is evidence in the benefits of the AGB placement in patients with hiatal hernia and GERD. Methods: Under general anesthesia, with the patient in french PRESENTER: Marcos Berry (Clinica Las Cndes, Santiago, position, the first trocar is placed 10mm to the left of the umbilicus Chile) and 10cm under the rib cage. The rest are placed under direct vision. We identify anatomical landmarks and dissect the pars flacida with Background: Conversion to sleeve gastrectomy is one sensible option the electrocautery continuing with phrenoesophageal membrane to when gastric banding fails. The reasons are various: slippage, gastric the His angle, the crura is dissected achieving complete esophageal dilatation, migration , port problems, insufficient weight loss and mobility. The crura is closed with separate stitches of ethibond 00. intolerance. The gastric band is placed and Dorr-type gastric plication with Our objective is to present our experience in performing sleeve ethibond 00 is done. The gastric band tube is extracted from the gastrectomy in one time surgery with the removal of a failed gastric abdominal cavity and the trocars are removed under direct vision. band. The port is fixated with prolene 00 and the skin is closed with Methods: Methods: Retrospective case series of 26 patients who monocryl 000. underwent this one time surgical procedure from June 2006 to Results: We included a total of 407 patients that underwent AGB February 2009. The indications for convesion were: Slippage in 3 placement from September 2008 to February 2010. Eighty two of patients, Banding intolerance in 6 patients, Insufficient weight loss in these patients had a hiatal hernia which was repaired during AGB 17 patients. placement (20.1%), 22 of these had GERD controlled with Results: Results: All patient better their quality of life after surgery. medication (5.68%), 12 had GERD without taking any medication In the group of insufficient weight loss the mean EWL was 11%. The (2.94%), and 48 patients were asymptomatic (11.79%). mean BMI prior conversion was 34,3. The EWL was 34,3% and Conclusion: Morbid obesity increases the intraabdominal pressure, 82,4% at 3 months and 12 months after conversion to sleeve, alters gastric emptying, decreases the pressure of the lower respectively. Morbidity of procedure was 7,7% including: one patient esophageal sphincter and increases its relaxation. AGB placement is with dysphagia, and one with hemoperitoneum. No patient had to be feasible in the presence of hiatal hernia as long as the crura is reoperated. No mortality recorded in this series. repaired. Conclusion: Conclusion: One time conversion procedure from a failed gastric band to sleeve gastrectomy is a secure procedure which better the quality of life and improves the loss of weight excess. P-104 Medium Term Results Of Laparoscopic Vertical Sleeve Gastrectomy In 300 Obese Patients P-106 Influence Of Type 2 Diabetes Mellitus In The Evolution PRESENTER: Juan Contreras (Clinica Santa Maria) Of Weight Loss In Obese With Bariatric Surgery

Co-authors: Diva Villao1, Jorge Bravo1, Ismael A. Court1 PRESENTER: Juan Contreras (Clinica Santa Maria)

1. Surgery and Bariatric, Clinica Santa Maria, Santiago, D.F., Chile. Co-authors: Diva Villao1, Jorge Bravo1, Ismael A. Court1 Background: Laparoscopic vertical sleeve gastrectomy (VSG) is one of the accepted procedures for weight reduction and control of 1. Surgery and Bariatric, Clinica Santa Maria, Santiago, D.F., Chile. comorbidities in obese patients. Methods: Prospective uncontrolled Study from November 2005 to Background: Bariatric surgery is an effective tool for weight control May 2009 which includes 300 patients undergoing to VSG by the and comorbidities in obese patients. The coexistence of type 2 same team and under the same standards of surgical technique, diabetes mellitus (DM2) would be an important factor that would preoperative evaluation and postoperative management. influence these results. Results: We report 35% men and 65% women. Average age: 39.7 ± Methods: Prospective uncontrolled study comparing weight loss in 10.5 years, preoperative weight: 111.8 ± 22 kg and BMI: 40.6 ± 6.7 obese patients with and without DM2 undergoing laparoscopic kg/m2. Obese 14.3% were grade I, grade II: 40.7%, Grade III: 35% vertical sleeve gastrectomy (VSG) or Gastric Bypass (RGB) from Megaobesidad: 8.7% and superobese: 1.3%. Concomitant pathologies April 2003 until May 2009. The surgeries were performed by the were found in 96%, such as dyslipidemia (64%), insulin resistance same team and under the same standards. (62.7%), steatosis (58.6%), hypertension (37%), sleep apnea (35.7 Results: Of the 466 patients, 300 were VSG and 166 RGB. VSG %), esophageal (34%), osteoarticular pathology (26.7%), group presented DM2 7.7%. This group showed a lower percentage hypothyroidism (21.3%), impaired glucose tolerance (17.3%), of excess weight loss (% EWL) at 6 and 12 months of 50 ± 17% and cholelithiasis (8.6%) and diabetes (7, 7%). Average operating time: 64 ± 18% vs 75 ± 25% and 83 ± 29% found in patients without DM2 71 minutes and hospitalization: 5 days. It was reported 3% of respectively (p <0.01). In the RGB Group, the 32.5% were DM2, Bellotte1, Deborah Moynihan1 showing a %EWL at 6 and 12 months of 64 ± 19% and 77 ± 21% vs 74 ± 14% and 92 ± 21% in patients without DM2 (p <0.01). Overall 1. General Surgery - Section of Bariatric & Advance Laparoscopic it was found that the %EWL in DM2 at 6 and 12 months was 60 ± Surgery, West Virginia University, Morgantown, WV, United States. 20% and 74 ± 21% v / s 75 ± 23% and 87 ± 26% in DM2 patients (p <0.01 ). The DM2 patients undergoing RGB have higher a %EWL at 12 months than the same group underwent VSG (p = 0.04). Background: Bariatric patients are at high risk for deep venous Conclusion: Patients with DM2 have a statistically lower %EWL in thrombosis (DVT) & pulmonary embolism (PE). Recently, the ACS medium term, regardless of procedure performed. These same group & the ASMBS established the concept of Centers of Excellence have a significantly higher % EWL when a RGB is performed. (COEs) focusing on standardizing the individuals programs‘ Therefore, the DM2 is an important factor to consider in the approach to manage the patients. We present our standard pathway & evolution of weight loss after bariatric surgery. results for prevention of DVT & PE. Methods: Between 07/2008 & 08/2009, 142 patients underwent bariatric surgery at West Virginia University (WVU) by the same surgeon (EA). Patients received education about DVT & PE P-107 Gastrojejunal Calibrated Anastomosis in Laparoscopic prevention pre-op. Post-op, patients were ambulated 4 hours after Roux-en-Y Gastric Bypass: Do We Really Need The Ring To Get being transferred to the floor. Patients received 1 dose of low the 12mm Diameter? molecular weight heparin (LMWH) (30 mg subcutaneously) pre-op & then 30mg every 12 hours each day. Sequential Compression PRESENTER: Nilton Kawahara (University of Sao Paulo School Devices (SCDs) were also applied to patients. Both discontinued on of Medicine) discharge after confirming ambulation. All patients were instructed to

2 1 walk at least 30 minutes a day. Data was collected prospectively. Co-authors: Clarissa Alster , Igor Praskurkin Results: We divided the patients into 2 groups, group A: 1 year follow up after the surgery (n=48, 33.8%), & group B: 6 months 1. Surgical Technique, University of Sao Paulo School of Medicine, follow up (n=80, 56.3%). 14 patients had no follow up (9.85%). Sao Paulo, Brazil. There were no patients who developed DVT or PE (0%). 22 patients 2. Topographic Anatomy, LIM02, University of Sao Paulo School of (15.5%) had higher risk for hyper coagulation including cancer, A- Medicine, SP, SP, Brazil. fib, anti-contraception, heart failure, & liver disease. 10 patients (7%) were on anti coagulation treatment for other medical conditions. Background: The diameter of the gastrojejunal anastomosis is Conclusion: Early ambulation on the same day of surgery, SCDs & important during alimentary restriction which should lead to weight LMWH seem to significantly minimize the risk of postoperative loss. Surgeons who perform RYGB with ring acknowledge its DVT & PE. Preoperative IVC filter should be considered in selected importance and usually say that the ring would guarantee a 12mm patients. anastomosis because of the idea that the anastomosis would enlarge. Numerous variations of the laparoscopic Roux-en-Y gastric bypass (RYGB) have been performed, including placing a ring proximal to P-109 Robotic-assisted Laparoscopic Bariatric Surgery: Initial the gastric outlet, in order to enhance the restrictive component to Results From 71 Patients achieve better weight loss (silastic ring RYGB), minimizing complications such as dumping syndrome. On the other hand, a PRESENTER: Daniel Tran (Blue Point Surgical Group) gastrojejunal calibrated anastomosis(GJCA) could reach the same result without the complications associated with the foreign body Co-authors: Denis Halmi1, Evgeni Kolesnikov1 silastic ring. Methods: We created a rigid inspection protocol to standardize the 1. Blue Point Surgical Group, Woodbridge, VA, United States. GJCA performed during RYGB. Morbidly obese patients were submitted to laparoscopic RYGB prospectively by a single surgeon. The gastric pouch was performed with linear stapler and the Roux Background: The advancement in robotic technology heralded in a Limb was created end-side with the GJCA hand-sewn performed. new era of minimally invasive bariatric surgery. We report our The staples belonging to the end of the staplerline were taken out experience with the first 71 robotic-assisted laparoscopic Roux-en-Y together with a 15mm incision by an ultracision harmonic scalpel gastric bypass (RA-LRNYGP) and laparoscopic adjustable gastric LCS-C5 (Ethicon Endo-surgery, Cincinnati, OH)(C=2.PI.R). The banding (RA-LAGB). diameter of the GJCA laparoscopically performed was compared Methods: Demographics, co-morbid conditions, surgical history, postoperatively by endoscopy after 5 years of follow-up. operative time, length of stay, complications, and postoperative Results: 220 patients were evaluated. 51% were grade III, 34,9% weight loss were recorded and analyzed for the first 71 bariatric were grade II with commorbidities and 7,1% were superobese and operations performed using the da Vinci robot at our institution. 0,55% supersuperobese. 71,82% were females. Mean GJCA diameter Results: 50 patients underwent RA-LRNYGB while 21 had RA- was 11,75+-1,23mm; Mean Pouch was 3,02+-0,5mm. Both the LAGB. There were 62 females and 9 males with the average age of diameters of the Pouch and GJCA were significant(p<0,05). Stenosis 46 years (25-68) and mean preoperative BMI of 44.2 kg/m2 (38-56). was present in 4%. 58 patients (82%) had one or more co-morbidities while 47 (66%) Conclusion: Neither hand-sewn GJCA nor the pouch created in a had at least one previous abdominal operation. The mean operative standardized RYGB dilate over time. time was 96 minutes (60-135) for the gastric banding and 200 minutes (150-360) for the gastric bypass. The average hospital length of stay for the RA-LRNYGB and RA-LAGB was 2.3 and 1.1 days, respectively. There was no conversion or major intraoperative P-108 Standardized Protocol for Deep Venous Thrombosis and complication. Postoperatively one patient developed stricture at the Pulmonary Embolism prophylaxis. A Simple Pathway to gastrojejunostomy that required dilatation, and another developed Minimize the Risk of Thromboembolism after Bariatric Surgery non-fatal pulmonary embolism. Excess weight loss was 47% at 3 months and 65% at six months for the RA-LRNYGB, while it was PRESENTER: Ehab Elakkary (West Virginia University) 23% at 3 months and 25% at six months for the RA-LAGB. Conclusion: Our initial experience with robotic-assisted bariatric Co-authors: Mohannad Kusti1, Forrest Olgers1, Lori Groves1, Travis surgery suggests that this is a safe alternative with comparable results 67,9 /12,2 /18,6 months to conventional laparoscopic surgery. We believe that superior Results: There has been one late death after SG because of a precision along with three-dimensional view afforded by the robot streptococcic cutaneous infection before the conversion into MBP. will allow more complex procedures to be performed with excellent The overall complication rate was 36 % (Gr1 after 67.9 mths ) , 10 % results. (Gr2), 19.6 % (Gr 3) . The reoperation rate was 34% (9 conversion into MBP), 20 % (10 conversion into MBP), 6% (2 leakages and 1 deep abscess) .49/64 GB are still in place ( 76%). P-110 Efficiciency Of Air Filled Balloon In Management Of The mean BMI (kg/m2) was respectively at 3 months : 47,6 / 47,2 / Obesity: Italian Experience 48,1 ; at 6 months 45,2 / 44 / 40,6 ; at 12 months 42,1/ 42,1 /34,1; at 18 months 39,2 / 42,1 / 34,7 and at 24 months 39 / 37,3 / 31 . MBP PRESENTER: Alessandro Giovanelli (Cliniche Humanitas led to significantly less complications (p<0.05) and less reoperations Gavazzeni, Bergamo, Italy) (p<0.001) than GB. BMI under 35 was significantly more frequent after MBP than after GB at one (p<0.001) and two years (p<0.005) . SG had less complications but required 1/5 conversions into MBP Background: Intragastric balloon may be used in obesity when other after a mean period of 15.8 months. . treatment is not successful or patients can not be treated with drugs, Conclusion: After two years MBP had better results than GB and SG surgery in general anaesthesia for cardiovascular, respiratory or for SO patients. It should be compared with Biliopancreatic diversion metabolic pathologies or in morbid obesity with co-morbidities to in these severe cases. induce body weight loss before surgery. An interdisciplinary approach is related to the best results and weight loss maintenance. Methods: Method: 2039 patients have been treated in Italy with intragastric air-filled balloon since 2004. 1796 were removed till February 2010. 51,5% of cases with mean BMI 33,8 (30-35) and EW: 27,3 Kg (range 13-43) F:M 4:1 mean age 32,4 (16-70); 48,5% were morbid obese patients with mean BMI 43,5 (range 35-76) (7,2% with BMI>50), F:M 2:1, mean age 37,7 (range 15-67) and EW 43,1 Kg (range 24-161). Balloon insertion and removal (after six months, following a multidisciplinary approach) was successful in all the procedures without general or anaesthesiological problems. Results: RESULTS: Good compliance during the treatment. Complications: 2,7% removals before six month for severe abdominal pain (0,6%), psychological intolerance (0,8%) or inefficacy (1,3%). 1 patient underwent surgery for bowel migration. Adverse events: 5,2% gastric failures, 4,5% vomits more than three days, 2,6% abdominal pain, 4,3% epigastric discomfort. Good weight loss in our series: - in BMI <35 WL 12,2+/-1,14 kg with EPWL 62% - in BMI 35-50 WL 19,8+/-1,2 kg with EPWL 51,3% - in BMI >50 WL 15,9+/-2,6 with EPWL 35% Conclusion: CONCLUSIONS: air-filled intragastric balloon may be used in weight loss control when surgery or drug therapy is not available. The procedure is efficient and safe with this new device.

P-111 Which Surgery For Superobese Patients ? A Retrospective Comparison In Favor Of Minigastric Bypass Compared With Gastric Banding And Sleeve

PRESENTER: Jean-Marc Chevallier (Chirurgie Digestive et de l'Obésité Secrétaire Scientifique de la SOFFCO Hôpital Européen Georges Pompidou)

Co-authors: R. Arienzo1, A. Saad1, F. Zinzindohoue1, G. Chakhtoura1

1. Chirurgie Digestive et de l'Obésité Secrétaire Scientifique de la SOFFCO Hôpital Européen Georges Pompidou , Paris, France.

Background: Superobese (SO) patients (BMI> 50 kg/m2) have the highest risk of comorbidities and death and also the most important risk of operative complications. We analysed efficiency and safety of three procedures: Gastric banding (GB), Sleeve gastrectomy (SG). and minigastric Bypass (MBP). Methods: between 1996 and 2009 695 SO have been operated out of 3555. We retrospectively compared the results of three groups: Group 1,GB (n=64), Group 2 SG (N= 50), Group 3 MBP (N= 51) . Mean age was 42,7 /44,9 /42,4 years. Mean operative Weight 147/151.6 / 154 Kg and mean BMI 54.5 /52,8 / 55,7 kg/m2. Mean follow-up was very different according to the evolution of respective indications: IHP-001 Surgical Weight Loss In The Elderly: Is It Worth patients (<1.5 years), 2) „Maintaining the Journey‟ including The Risk? patients more than 1.5 years post-surgery, and 3) „Friends and PRESENTER: Jayashree Todkar (Ruby Hall Clinic) Family‟. Each support group session is structured for one 1 1 hour, once per month, with a specific topic focusing on the Co-Authors: Shashank S. Shah , Poonam S. Shah emotional and psychological aspects of obesity and lifestyle changes required for long-term weight loss success. 1. Surgery, Ruby Hall Clinic, Pune, Maharashtra, India. Results: Our current program includes the 3 basic monthly Background: Bariatric surgery after 60 yrs age is regarded support groups and additional services have evolved to unsafe for morbidity / mortality concerns. This study aims at provide for regular Bariatric Cooking Classes, Obesity evaluation of Bariatric surgery in elderly Sensitivity Staff Workshops, individual psychotherapy for Methods: This is Retrospective analysis of prospectively initial adjustment issues, and „on line‟ educational support maintained continuous database regarding safety, operative workshops. The current program has been highly successful, morbidity and outcome in elderly . as assessed by group evaluation scores and monthly Since 2004 , 500 patients underwent bariatric surgery at attendance. Laparo-Obeso Center , 69(M:F=35:34) above the age of 60 yrs Conclusion: Based upon our experience, we firmly believe .The BMI distribution : 35 to 40 kg/m2 (28), 40 to 50 that patient support and knowledge of skills important for kg/m2(29), 50 to 60 kg/m2 (10 ),above 60kg/m2(2). The emotional and physical well-being are fundamental to long- distribution per type of surgery :Adjustable Gastric Banding : term surgery success. 17,Laparoscopic sleeve gastrectomy: 42,Laparoscopic roux -en -y gastric bypass:10 Results: Pre operative risk profile :Obstructive sleep apnoea: IHP-003 Lap Band-“Is it a durable bariatric procedure?” 12 ,Diabetes:49 ,Hypertension : 49 ,Dyslipidaemia : 61 ,Joint The Wesley Brisbane experience pains : 65 , liver cirrhosis :2 , congestive cardiac failure : 2, chronic renal disease : 1 . Hospital stay : 3.5 days avg , PRESENTER: Bhavik Patel (Royal Brisbane Hospital) operative time :90 min avg ,30 days readmission :zero.Post Co-authors: Blair Bowden2, Jenny Duncombe2, George operative complications : one mortality due to Myocardial Fielding2 Infarct on day 5 ,no bleeding /pulmonary/wound complication. %EWL is 62% at the end of one year.One patient needed band 1. Royal Brisbane Hospital, Brisbane, QLD, Australia. removal for erosion ,two patients had nutritional complications 2. wesley hospital, Brisbane, QLD, Australia. in the form of protein , vit B12 defficiency and was corrected conservatively. Background: Wesley Private hospital has been a world leading Conclusion: This shows that bariatric surgery in elderly is safe centre for bariatric surgery in, Brisbane, Australia. We have and effective.This is the first study of outcomes of Bariatric been involved with laparoscopic adjustable gastric band surgery in elderly Indians. surgery since 1996. Since that time we have performed over 3000 primary lap band procedures. In this study we hoped to ascertain the long term durability of the procedure over an IHP-002 The Establishment of Support and Educational eight year follow up period Programs for Long-term Surgery Success Methods: We have conducted a retrospective analysis of all patients who underwent LAGB surgery at our institute from PRESENTER: Krista Castleberry (Florida Hospital 1st January 2000 to 31st December 2000.The end points were Celebration Health) related to the outcomes in terms of weight loss and complications Co-authors: Patricia J. Toor1, Keith Kim1, Cynthia K. 1 Results: 158 patients underwent LAGB surgery during the Buffington above period. There were 135 females and 23 males in this 1. Metabolic Medicine and Surgery Institute, Florida Hospital study. The age ranged from 13-69 years. Mean age of 41 Celebration Health, Celebration, FL, United States. years. The mean weight on presentation was 127 kilograms .The current mean weight is 104kg. 70 % follow- up rate over Background: Behavioral and psychological factors play an eight years .There was no mortality in our series. important role in the success of bariatric surgery. Studies find Conclusion: LAGB surgery has proven durability over an that postoperative psychological support increases patient eight year period in our series with a minimum of morbidity compliance and contributes to more successful surgery and no mortality outcomes. In this report, we discuss the issues involved in establishing a bariatric psychosocial support and educational program. IHP-004 Analysis Of Body Composition Evolution After Methods: Different analyses, including the literature review, Roux-En-Y Gastric Bypass were used to establish structure and content for the program. Surgeon, multidisciplinary team, and patient needs assessment PRESENTER: Silvia Faria (Gastrocirurgia de Brasília) data were collected through shadowing daily practices and Co-authors: Orlando P. Faria1, Margaret Furtado2, Renato interviews. The feedback was consistent from staff and Lins1, Cynthia K. Buffington3 patients for a division of support into 3 separate groups: 1) „Beginning the Journey‟ consisting of early postoperative 1. Gastrocirurgia de Brasília, Brasília, Distrito Federal, Brazil. 2. Clinical Nutrition, Johns Hopkins Bayview Medical Center, likelihood of success (%, GB= 92, LB=92, SG=91). A Baltimore, MD, United States. significant difference existed for patients assigning surgery as 3. Florida Hospital Celebration, Celebration, FL, United the most important factor for success (%, GB= 54, LB=17, States. SG=15). For the URICA survey, no significant differences existed (GB= 10, LB=10.1, SG=10.9) with all likely to Background: Roux-en-Y gastric bypass (RYGB) is an change. effective tool in weight loss success and maintenance. Conclusion: This is the first study to date comparing However, for maximal effectiveness, it is important that motivations and its effects among different bariatric during weight loss, there is only a minor decline, or even procedures with gastric bypass patients assigning more preservation, of lean tissue mass in order to maintain basal importance to the surgery than other patients. Further analysis metabolic rate (BMR). In the present study, we have examined will reveal correlation between pre-op motivations and post- BMR in relation to changes in body composition following op outcomes. RYGP. Methods: Fifty-one patients participated in the study. Anthropometrics (weight, height, body mass index, body IHP-006 Bariatric Surgery At Sunninghill Hospital, A composition) and basal metabolic rates were measured South African Bce: Pre-Operative Patient Profiling preoperatively and at postoperative months 3, 6, 9, and 12. Body composition was assessed by multifrequency PRESENTER: Maria-Terésa Van der Merwe (Metabolic bioimpedance (Inbody® 720) and BMR was calculated by Medicine and Surgery) Inbody® 720. Data was analyzed using Tukey‟s test. Co-authors; Jenny H. Pieters1, Annelie Maree1, Gary K. Results: The study data show a loss of muscle mass over time Fetter1 post-RYGP. The largest loss of muscle mass (MME) occurred in the first 3 months after the operation (4.54 kg). In the 1. Centre of Excellence, Metabolic Medicine and Surgery, second trimester, the loss was smaller (0.70 kg). Between the Lyttelton, Gauteng, South Africa. sixth and the twelfth postoperative months, MME loss was non-significant. Percentage (%) body fat declined from 48.7% Background: Disease profiling in patients preparing for preoperatively to 38.5% by postoperative month 12, and the surgery. fall in fat mass was significant across all measurement Methods: 1. 315 (233F; 82M) patients assessed 2007 - 2008. periods. There was a positive correlation (0.59) between the History recall, clinical and special investigations. 2. Pre- BMR and MME, and a negative (-0.34) and significant operative gastroscopy: N=196. (p=0.02) correlation between BMR and % body fat. Results: Age M 42.9 ± 2.0y, F 38.8 ± 2.1y; Weight M 153 ± Conclusion: Anthropometric follow-up is fundamental for 8kg; Height M 1.76 ± 0.15, F 1.65 ± 0.1cm; BMI 49.5 ± 2.7, F bariatric patients. Lean mass maintenance is important for 44.3 ± 1.0; Neck circumference M 53.2 ± 3, F 45.5 ± 0.5cm; maintaining basal metabolic rate, which is fundamental for Waist M 143.8 ± 4.8, F 127.5 ± 1.9cm; BP M 157/93, F long-term weight loss success and maintenance. 143/85 mmHg. Conclusion: 1. Patients presenting for surgery have longstanding histories of obesity and and co-morbidities. 2. IHP-005 Are There Different Motivations for Different Patients presented for surgery in their 3rd – 4th decade. 3. Bariatric Surgeries? Male patients have a more adverse clinical profile. 4. Abnormalities on g-scope prevalent. PRESENTER: Shushmita Ahmed (Stanford University) 1 1 Co-authors; Eric Changchien , Tina Boussard , John M. % of total Morton1 History: N=315 1. Surgery, Stanford University, Stanford, CA, United States. Family history of obesity 94.8 Background: Few studies have examined patients‟ motivations for undergoing bariatric surgery. Our aim is to elucidate Weight gain > 10kg from 18y 86.2 different patient motivations across procedures and correlate Childhood obesity 73.4 these motivations to long-term outcomes. Methods: 80 consecutive patients undergoing bariatric surgery Cessation of smoking 23.1 [gastric bypass (GB), n=53, laparoscopic gastric banding Post-partum weight gain > 10% 48.4 (LB), n=12, or sleeve gastrectomy (SG), n=15] were recruited. History of eating disorder 11.9 Patients were administered previously validated questionnaires at preoperative visit to assess motivation for Failure of obesity pharmacotherapy 76.9 surgery and readiness to change (University of Rhode Island Comorbidities (N=315) Change Assessment, URICA). Continuous and categorical Arthropathy/OA 81.7 data were analyzed by ANOVA and Pearson‟s Chi-Square as appropriate with p<.05 Sleep apnoea 69.6 Results: There were no significant differences between the Depression 56.9 procedures for patients expressing health as primary motivation (%, GB= 88, LB=80, SG=86) or their perceived PCOS± infertility 35.0 IGTT/DM 29.9 de Dinant) 1 1 NASH 26.3 Co-authors: Gaël Jacquemin , Jean-Paul Boeur IHD 18.4 1. General, Digestive and coelioscopic Surgery, Centre G-scope: (N=196) Hospitalier de Dinant, Dinant, Belgium.

Esophagitis/Gastritis 23 Background: Laparoscopic Gastric Bypass as become a Hiatus hernia 14.3 widely performed procedure. Helicobacter pylori 10.2 Several surgical approaches, each as efficient as the other, have been published. In Europe and particularly in Belgium Public Health Costs are challenged by the incredible price of these procedures. IHP-007 The Effect of a Hospital Bariatric Service Line on Furthermore most of them require many “co”-operators not Patient Satisfaction always available in every Departement. Methods: In our department, based on the excellent technique

of Dr. B. Dillemans, we developed a safe and cost effective PRESENTER: Patricia Toor (Florida Hospital adaption.We present our serie of more than 160 patients. Celebration Health) Using pictures, diagrams and videos all the steps of the Co-authors; Sandra Reeder1, Keith Kim1, Cynthia K. procedure are developed. Buffington1 Results: We can now perform LapRnYGBP with only two operating persons( a surgeon an just an help) in less than 75 1. Metabolic Medicine and Surgery Institute, Florida Hospital min skin to skin, including mesenteric defects closure. Celebration Health, Celebration, FL, United States. This technique fits the Health Care reimbursement and is all the more reproducible. Background: The bariatric service line is a multidisciplinary It can be used in most patients, be they first or revision cases. program concentrating on the educational and medical needs Conclusion: We now have sufficient background to assess that of the patient pre- and postoperatively and during their this technique can easily be performed in small units, in a safe hospital stay. The service line provides specific education to and cost effective way. the healthcare staff of bariatric patients to assure optimal outcomes and patient satisfaction. In the present study, we examine the influence of service lines on HCAHPS (Hospital IHP-009 Laparoscopic Adjustable Gastric Banding Consumer Assessment of Healthcare Providers and Systems) Surgery as a Treatment Modality for the Management of scores of bariatric patients. Morbid Obesity in patients over 60 years with Multiple Methods: HCAHPS is a national standardized survey of Comorbidities hospital patients created to report the patient‟s perspective of hospital care. Hospitals randomly send the surveys to patients PRESENTER: Danny Sherwinter (Maimonides Medical following discharge. The survey measures patient satisfaction Center) with services and hospital personnel including staff responsiveness, pain management, discharge information, Co-authors: Jesus Hidalgo1, Jerzy Macura1, Harry Adler1 medication instruction, communication (nurse/physician), and 1. Maimonides Medical Center, Brooklyn, NY, United States. the hospital environment. Results: The data show that service lines result in significantly improved patient satisfaction (p<0.01). Bariatric HCAPHS Background: The presence of multiple comorbidities in the scores for 6 of 8 surveyed items were in the 95th. percentile of aged population begs for a more rigid appraisal of the risks national scores and were higher than those of the overall and benefits of bariatric surgery. The aim of this study was to hospital system and the medical-surgical unit that shared the examine the outcomes of laparoscopic adjustable gastric band same hospital environment. The HCAHPS score for all as a treatment modality in patients over 60 years with surveyed items averaged 83.7% for the bariatric patients as multiples comorbidities. compared to 69.6% (p<0.01) for the hospital system and Methods: We reviewed our prospectively collected data from 62.7% (p<0.01)for patients on the same medical-surgical unit. over 400 patients who underwent LAGB from 2004 to 2009. Among the bariatric patients, 94% reported a willingness to Data collected included demographics, comorbidities, recommend the hospital services, as compared to 73% of preoperative BMI, preoperative weight, postoperative BMI, patients hospital-wide and 69% of those on the unit. postoperative weight, postoperative complications and Conclusion: A bariatric hospital service line results in highly mortality. Follow-up time: ranged from 6 to 60 months. significant improvement in patient care and satisfaction. Results: 17 patients older than 60 underwent LAGB in this series. Mean age was 62 (range 60-70) years. Mean preoperative BMI was 44.5 (range 36 -68) Kg/m2. Mean IHP-008 Laparoscopic Gastric Bypass,A Safe, Cost- preoperative weight was 282.8 (range 222-485) lbs. Mean Effective, Rapid And Personnal Technique For Small postoperative BMI and postoperative weight was 32 Kg/m Surgical Units. range (23-41) and 234.8 (range1878-425) lbs, respectively. 82% of patients presented with diabetes, 76% sleep apnea,

71% hypertension, 47% obstructive sleep apnea, 47% PRESENTER: Jean-Philippe Magema (Centre Hospitalier hypercholesterolemia, 24% asthma, 17% shortness of breath, 17% GERD, 17% depression, 6% hypothyroidism and 6% CAD. Among the patients, 94% (16) were ASA III and 6% (1) were ASA II. Three of the patients required revisional surgery for slippage and 1 for port revision. There was no mortality in this series. Conclusion: LAGB appears to be safe and effective in patients older than 60 years with multiple comorbidities regarding the high operative risk that these medical conditions represent in this vulnerable population.

IHP-011 Case Study: Control Of Recurrent Clostridium IHP-010 Gallstone Ileus After Roux-En-Y Gastric Bypass Difficile With Beneficial Bacteria In Combination With Conventional Antibiotic Therapy In Patients Previously PRESENTER: Jesus Hidalgo (Maimonides Medical Unresponsive To Antibiotic Therapy Alone. Center) Co-authors: Jerzy Macura1, Harry Adler1, Danny A. PRESENTER: Barbara Metcalf (Pacific Laparoscopy) Sherwinter1 Co-authors; David Caya1, John Rabkin1, Dana Benner1 1. Maimonides Medical Center, Brooklyn, NY, United States. 1. Pacific Laparoscopy, San Francisco, CA, United States.

Background: Due to the low incidence (0.3-0.5%) of gallstone Background: The most complained of side effects of the short ileus on the general population and to the high percentage (10- gut created in the Duodenal Switch (DS) patient are multiple 15%) of bariatric patients that undergo cholecystectomy, loose stools and malodorous flatus. It was gallstone ilues is an unexpected post-bariatric complication. theorized that these symptoms were due to subclinical C.diff We present a case of gallstone ileus after Roux-en –Y Gastric infection. It has been our recent experience that these Bypass. To our knowledge this has not been described in the symptoms can be greatly ameliorated by the use of probiotic literature. bacteria including the species S. boulardii. In addition, an Methods: N/A increasing number of post-operative patients are experiencing Results: The patient is a 38-years-old female with a history of chronic recurrent C. diff infections. We report on 7 patients Roux-en-Y Gastric Bypass in 2004.She presented to our after the DS who were not responding to conventional institution in September 2009 with left flank pain 7/10 in antibiotic therapy. intensity and bilious vomiting for one day. Her vital signs Methods: Added to the existing antibiotic regimen consisting were within normal limits. On physical examination she had a of Vancomycin 125-250 mg QID x 14 days was a high quality soft, mildly distended abdomen and was tender in the probiotic supplement. Probiotic product containing epigastrium. CT scan clearly showed small bowel obstruction 3 billion colony forming units (cfu) S. boulardii and an in the mid ileum, pneumobilia and a radio-opaque foreign additional 12 species totaling 15b cfu‟s each cap, 1-3 cap‟s per body at the small bowel transition zone consistent with a day. gallstone seen on previous imaging. At laparoscopy the point Simple carbohydrates and processed foods are to be of transition was identified (figure 1-2), an enterotomy was eliminated or minimized. created and the foreign body removed (figure 3). Results: Symptoms completely resolved in three patients and Postoperatively she did well quickly resumed bowel function improved by 75% in one additional. None wanted to repeat and was discharged on postoperative day 4. stool cultures for confirmation. Patient non-compliance with Conclusion: Although internal hernias and adhesions remain diet was reported in two out of three patients whose symptoms the most common causes of small bowel obstruction in did not resolve. patients who have undergone a Roux-en-Y Gastric bypass, Conclusion: A probiotic blend containing appropriate species other causes, such as gallstone-ileus should remain in the may be given in therapeutic doses in addition to conventional differential diagnosis antibiotic to have a beneficial effect on C.diff infected gut not responding to antibiotics alone.

IHP-012 Thinking Beyond the Measuring Tape and BMI: Using Two and Three Dimensional Information to Evaluate the Obese Condition without a Weight Component

PRESENTER: Stephen Wohlgemuth (Sentara Hospital

System) Co-authors: David B. Stefan1 1. Novaptus Systems, Inc, Chesapeake, VA, United States. 2. Metabolic and Weight Loss Surgery Center, Sentara with subject weight creates a Bariatric Density. These new Hospital System, Norfolk, VA, United States. insights were compared to %EWL for a group of subjects. Methods: 200 pre-operative bariatric patients of various Background: Common measurements do not necessarily tell shapes and sizes were scanned using a commercial 3D whole the tale of the obese condition, or the degree of obesity of a body scanning device. Software was programmed to capture particular subject. A large waist measurement by itself might bulk volume of the patient. Weight and BMI were recorded. be an indicator of obesity, but not if it is associated with a Ideal weight was tabulated. Excess volume was determined by particularly tall subject. A large BMI might indicate an obese dividing bulk volume by weight, multiplying by excess condition, but the BMI formula penalizes shorter subjects and weight. Bariatric Density was calculated by dividing excess mesomorphic body types. By using surface area in squared volume with subject‟s weight. Information was recorded at 3 centimeters and volume in cubic centimeters, a new obesity month, 6 month and 12 month intervals. indicator has been developed that defines the “space” the Results: The group averages exhibited “normal” %EWL of individual occupies, regardless of the subject‟s height or 30%, 50% and 75% at recorded intervals. %EV displayed weight. 41%, 63% and 76%. The Bariatric Density displayed 31%, Methods: A 3D whole-body scanner was used to create an 52% and 65%. Startlingly, individual components displayed accurate, measurable body model of bariatric subjects. Surface little correlation during weight loss. A Bariatric Density Scale, Area and Volume Measurements were extracted. A ratio was in cc/kg was developed. developed that divides the subject‟s torso volume by the torso Conclusion: Volume relates to the overall size of the patient. surface area. This ratio was compared to the subject‟s BMI By calculating Excess Volume and using the weight and waist/hip ratio. component, a Bariatric Density was developed. Monitoring Results: This new ratio, independent of overall height and volume and density changes as weight loss occurs offers subject weight, accurately determined the overall adiposity of significant new insights as the body undergoes changes. an obese individual and differentiated the degree of adiposity Density implies a form of body composition and opens a new between individuals that have similar BMI and/or weight. dimension to understanding massive weight loss which must Conclusion: Viewing the subject in multiple dimensions be explored further. allowed the creation of The Torso Volume/Torso Surface Area Ratio, a new method of determining the adiposity of an obese subject. This ratio eliminates deficiencies associated with IHP-014 Determining Weight Loss Rates and the Optimal other indicators that rely on overall weight or height of the Weight Loss Point after Bariatric Surgery subject, or common circumferential measurements. PRESENTER: Stephen Wohlgemuth (Sentara Hospital System) Co-authors: David B. Stefan1 1. Novaptus Systems, Inc, Chesapeake, VA, United States. 2. Metabolic and Weight Loss Surgery Center, Sentara Hospital System, Norfolk, VA, United States.

Background: Weight loss progress after surgery is visually Two subjects with same weight and height, hence BMI. But evident and can be measured in various ways. However, their volume and surface area are different. The higher the determining the rate of weight loss and when the subject has TVSA the more obese the subject. achieved optimal weight loss has been elusive. A technique has been developed that measures and tracks the volume and surface area of a bariatric patient pre-operatively and post- operatively. Percent changes to volume and surface area IHP-013 Percent Excess Volume Loss vs. Percent Excess reduction after surgery determines the rate of weight loss. Weight Loss: The Bariatric Density and its Implications Optimal weight loss is achieved when volume and surface area changes stabilize and the slope of the weight loss curve PRESENTER: Stephen Wohlgemuth (Sentara Hospital reaches an inflection. System) Methods: Pre-operative patients were scanned using a commercial 3D scanning device. Initial measurements were 1 Co-authors: David B. Stefan extracted using embedded measurement tools, volume and 1. Engineering and Research, Novaptus Systems, Inc, surface area information was calculated. Patients were Chesapeake, VA, United States. scanned post-operatively every three months for a period of up 2. Metabolic and Weight Loss Surgery Center, Sentara to 18 months. Weight loss curves were developed using torso Hospital System, Norfolk, VA, United States. volume divided by torso surface area. The rate of weight loss was defined as the percent change in this ratio. The optimal weight loss point was declared when the slope of this curve Background: Percent Excess Weight Loss (%EWL) has been leveled or reached an inflection point. the standard for monitoring weight loss after surgery. By Results: This method categorized periods of rapid weight loss, obtaining the volume of the subject, one can determine the and detected when the rate of weight loss began to decelerate Percent Excess Volume (EV). Combining Excess Volume to the point where optimal weight loss was achieved. Results: Gastric Bypass improves in a surprising way glucidic Conclusion: Determining the rate of weight loss was helpful in homeostasis by mechanisms that go beyond the excesive assessing the progress of the post-operative bariatric patient weight loss. A lot of hormonal changes are implicated. and offered the ability to declare when optimal weight loss has Conclusion: Gastric Bypass is a well known bariatric been achieved. This technique may also be helpful in procedure, often considered as just a restrictive technique.The determining when to adjust lap bands to achieve an optimized different studies we reviewed clearly showed it has an outcome. important and well documented metabolic effect on type II diabetes.The role of Gastric Bypass on the intestinnal neo- glucogenesis is not yet well established. All these results are IHP-015 The Time Course Of The Improvement In very exciting but we should be carefull about eventual Depression Symptoms In Morbidly Obese Patients After unexpected long term consequences. Mini-Gastric Bypass Follows A Logarithmic Curve And Is Directly Related To Total Weight Loss PRESENTER: Robert Rutledge (Center for Laparosocpic Obesity Surgery, Henderson, NV, United States) Background: Obesity and depression are related. Weight loss has been reported to be associated with improvement in the Mechanisms implicated in Gastric Bypass in mice psychological functioning of morbidly obese patients. The time course of this change in depressive symptoms is unknown. This study compared the depressive symptoms before and IHP-017 Development Of A Advanced Bariatric after mini-gastric bypass. Practitioner Training Programme Methods: 3,325 patients underwent mini-gastric bypass and reported on the presence of depressive symptoms prior to surgery and at 1, 3, 6 and 12 months following operation. PRESENTER: Jayne Brocklehurst (Gravitas Centre for Results: Prior to surgery 34.4% of patients reported that they Bariatric Surgery) suffered from symptoms of depression. Following surgery Co-authors: Conor Magee1, Simon Weaver1, Robert overall 16.6% of patients reported symptoms of depression an Macadam1, Shafiq Javed1, David Kerrigan1 overall decrease of 48.2%. MGB resulted in a mean weight loss of 61.9+/-23 kg. The time 1. Gravitas Centre for Bariatric Surgery, Liverpool, United course of the resolution of depression followed a logarithmic Kingdom. decline. Improvement of psychological functioning was directly related to weight loss, y = 2.07*10-3 X + 5.81*10-1 Background:The bariatric surgeon, dietitian and nurse are all Correlation Coefficient: r = .67. key members of the team. However there is a large amount of Conclusion: Depressive symptoms are common before overlap in the roles undertaken by these specialists in the bariatric surgery and are improved by the MGB. outpatient management of bariatric patients. We believe that a Like other co-morbidities depressive symptoms often resolve new role of advanced bariatric practitioner (ABP) could be rapidly following surgery, but the success rte (48%) is lower developed for non surgical staff which could be undertaken by than for diabetes, hypertension etc.. The time course of the a either a dietitian or nurse after appropriate training. resolution of depressive symptoms follows a logarithmic curve Methods: A training package with aims and learning outcomes and the resolution of depressive symptoms is directly related was developed. This covered the essential components of the to the total weight loss. ABP role. Both dietitians and nurses underwent a period of training by experienced professionals until competence had IHP-016 Gastric Bypass: A Model Of Metabolic Surgery? been attained in all areas. Results: On completion of the ABP training programme both PRESENTER: Jean-Philippe Magema (Centre Hospitalier dietitians and nurses had acquired the skills necessary to carry de Dinant) out follow up assessments independently. This includes undertaking gastric band adjustments, providing appropriate 1 1 Co-authors: Arnaud Devresse , Gaël Jacquemin , Jean-Paul dietary advice, blood monitoring and recommendation of 1 Boeur supplements for nutrient deficiencies in line with standard 1. General, Digestive and coelioscopic Surgery, Centre protocols, which are performed in conjunction with an Hospitalier de Dinant, Dinant, Belgium. experienced bariatric surgeon. All practitioners can seek support from the relevant health care professional if required.

Conclusion: The ABP training programme has enabled us to Background: It is well known that Gastric Bypass has an early provide a more effective service for patients and has increased and powerful effect of the evolution of type II diabetes. Other the job satisfaction of dietitians and nurses working within our mechanisms than simple weight loss are concerned. units. Methods: We reviewed the litterature.We developped and summed up the different studies on the metabolic effects of Gastric Bypass.Alimentary intake, GLP-1,insulinosensibility, IHP-018 Contrast studies (CS) following primary bariatric intestinal neoglucogenolisis are among the implicated factors. procedures, is it obligatory? 1. obesity Surgery Center, kPJ Damansara Specialist Hospital, PRESENTER: Vasha Kaur (St George's Healthcare NHS kuala Lumpur, Malaysia. Trust) 2. Bariatric Surgery Center, Northwest Medical Center, margate, FL, United States. Co-authors: Sami Mansour1, Mohammad Mobasheri1, Rajesh Jain1, Georgios Vasilikostas1, Marcus Reddy1, Andrew Wan1 Background: Malaysia is a multiethnic nation with diverse 1. Bariatric Surgery, St George's Healthcare NHS Trust, religious beliefs that is westernizing at an alarming rate. The London, United Kingdom. population is 60% Malays who are Muslims, 25% Chinese who are mostly Buddhists, Taoists or Christians and a Background: Contrast studies (CS) are often advocated significant number of Indian who are Hindus. We present our following bariatric procedures to exclude anastomotic leaks. work on the creation of a bariatric surgical center in this We aimed to assess the utility of CS on patient outcome post- country. bariatric surgery. Methods: 50 patients had surgery for morbid obesity at the Methods: Patients undergoing primary bariatric procedures New Obesity Centre in Petaling Jaya, Malaysia between during our study period were divided into 2 groups. Patients in January 2007 and December 2009. 39 or 78% were Malay, 4% Group A routinely received CS post-operatively while in were Indian, and 16% were Chinese, Arabic or European. Group B no CS were performed. Outcomes in these groups 26 patients underwent laparoscopic gastric bypass surgery, 23 were compared in terms of leak rates and length of post- patients underwent laparoscopic gastric sleeve resection. operative hospital stay. There were 33 were females while 17 were males. Initial body Results: One patient in each group had an anastomotic leak. weight ranged from 72.3 kg to 210 kg. Both leaks were diagnosed clinically, confirmed intra- Results: There were 4 complications in all. In the sleeve operatively and subsequently repaired. However, CS in the group, there were 2 stenotic sleeves, one was converted to Group A patient failed to identify a leak. In addition, time to bypass, while in the other, the stenotic portion was resected, re-operation from onset of symptoms was 48 hours in the and the patient was resleeved. In the gastric bypass group, a Group A patient and under 24 hours for the Group B patient. trochar hernia and a subphrenic haematoma were successfully Conclusion: This study demonstrates no benefit in performing reoperated. There was no mortality in our series. Weight CS in bariatric patients post-operatively. Both leaks were loss,amelioration of co-morbidities, and follow up are identified clinically without CS. In patients with leaks, time to discussed. re-operation was shorter without CS. Furthermore, patients Conclusion: It is possible to create and maintain a bariatric who did not receive CS had shorter hospital stay with a surgical program that can subsequently set the standard for the possible reduction in associated costs. safe practice of bariatric surgery in Malaysia.

Results: Group A vs Group B IHP-020 Is Bariatric Surgery Safe In Patients Who Refuse Group A Group B Blood Transfusion?

(n=21) (n=15) Roux-en-Y bypass 16 (76%) 13 (87%) PRESENTER: Seiichi Kitahama (Oregon Weight Loss Surgery) Sleeve gastrectomy 5 (23%) 2 (13%) Co-authors: Mark D. Smith1, David R. Rosencrantz2, Emma Contrast studies 21 (100%) 0 (0%) Patterson1

-Leaks identified 1. Bariatric Surgery, Oregon Weight Loss Surgery, Portland, radiologically 0 - OR, United States. Leak suspected clinically 1 1 2. Bloodless Surgery Program, Legacy Health System, Portland, OR, United States. -Leak confirmed intra- operatively 1 1 Background: Jehovah's Witnesses represent an international religious organization with more than one million members in Mean post-op stay (days) 4.2 3.7

the United States. Incidence of blood transfusion after laparoscopic Roux-en-Y gastric bypass (LRYGB) was reported 0.4%, and 0% after laparpscopic adjustable gastric banding (LAGB). Furthermore, morbidly obese patients are often considered high risk for post-operative venous IHP-019 The Incidence And Co Morbidity Of Obesity And thromboembolism, reported rates from 0.08 to 4.5%. Selecting the method of antithromboembolism is challenging among The Preliminary Report of Bariatric and Metabolic these patients. Surgery In Malaysia Methods: A retrospective cohort of patients undergoing

bariatric surgery who refused blood transfusion at Oregon PRESENTER: Paul Wizman (Northwest Medical Center) Weight Loss Surgery over a ten-year period was reviewed. Co-authors: Haron Ahmad1, Wan Nik1 Patients were identified from a prospectively maintained database. These patients were enrolled in the Bloodless Surgery Program, where pharmacologic methods are used to IHP-022 International Prospective Randomized Study: prepare for and treat blood loss. Database was reviewed for Banded Versus Conventional Laparoscopic Roux-en-Y age, BMI, comorbidities, laboratory data, medication, use of Gastric Bypass – Preliminary Results after Patients

erythropoietin, thromboembolism prophylaxis, blood loss, and Enrolment 30-day complications. Results: Thirty-two patients who refused blood transfusion PRESENTER: W. Karcz (University of Freiburg) underwent bariatric surgery between 2000 and 2009. Twenty 2 10 patients underwent LAGB; twelve patients underwent Co-authors: Jan Willem Greve , Karl Miller , Tomasz 6 7 8 3 LRYGB. Before January 2006, only pneumatic compression Szewczyk , Mario Nora , Walid Bukhari , Bruno Dillemans , 4 5 9 devices were applied (n=6). Subsequently, combination Luc Lemmens , Jacques Himpens , Guenther Meyer prophylactic thromboembolisms were performed with 1. Dept. of General and Visceral Surgery , University of Fondaparinux sodium 2.5mg for LRYGB or enoxaparin 40mg Freiburg, Freiburg, Germany. for LAGB (n=26). One gastric bypass patient in the first group 2. Dept. of General Surgery, Atrium medical Centre, Heerlen, had postoperative bleeding. There were no DVTs or PEs. Netherlands. There were no deaths. 3. Dep. of General Surgery, Hospital AZ St. Jan, Brugge, Conclusion: Bariatric surgery can be safely performed in Belgium. patients who refuse blood transfusion. Larger studies are 4. Dept. of general Surgery, Hospital AZ Niklaas, Sint- necessary to confirm the safety of Niklaas, Belgium. pharmacologicalthromboprophylaxis in this patient group. 5. Dept. of General Surgery, Hospital AZ Blasius, Dendermonde, Belgium. 6. Dept. of General Surgery, University of Lodz, lodz, Poland. IHP-021 Prevalence of Iron Deficiency Following 7. Dept. of General Surgery, Hospital de Sao Sebastiano, Laparoscopic Roux-en-Y Gastric Bypass Santa Maria da Feira, Portugal. 8. Dept. of General Surgery, International Medical Center, PRESENTER: Jayne Brocklehurst (Gravitas Centre for Jeddah, Saudi Arabia. Bariatric Surgery) 9. Dept. of General Surgery, Chirurgische Klinik München- Bogenhausen, München, Germany. Co-authors: Conor Magee1, Simon Weaver1, Robert 10. Dep. of General Surgery, Hospital Saalfelden, Saalfelden, Macadam1, Shafiq Javed1, David Kerrigan1 Austria. 1. Gravitas Centre for Bariatric Surgery, Liverpool, United Kingdom. Background: M. Fobi and co-workers developed banded gastric bypass (BRYGB) in 1998 (publication year). Safety Background: The aim of this study was to evaluate the and feasibility are demonstrated with an increased excess incidence of iron deficiency following Laparoscopic Roux-en- weight loss more than 70% and no increased postoperative Y Gastric Bypass (LRYGB). complications. Methods: 163 patients (132 female and 31 male) with at least The Aim of this international project is to evaluate, if an one year of follow up were studied. All started a multivitamin additional restrictive silastic ring can avoid dilation of the and mineral preparation post operatively which contained gastro-entero anastomosis and adjacent small bowel with 12mg Iron. Blood tests were analysed at 3,6,9,12,18 and 24 consecutive better postoperative weight loss and significantly months. Patients with pre-existing anaemia were excluded. improved long-term weight maintenance. Chi squared tests were used for statistical analysis. Methods: : The study is performed in ten centres of excellence Results: Median age was 42 years (range 19-67) and median worldwide using standardised gastric bypass procedures. Our pre operative BMI 48.4Kgm2 (range 32.6-68). Median % study Inclusion criteria: age 21-60 years, BMI ≥ 40 kg /m2 to excess weight loss was 75% and 81% at 12 and 24 months 50 kg/m2, eating habit: sweet eater and volume eater, signed respectively. Twenty percent of patients developed iron informed consent. deficiency, with 50% of these presenting with iron deficiency The enrolment of the trial patients started on 1st April 2009 anaemia. Iron deficiency was more common in females aged and will be ended on 1st July 2010. I was planed to evaluate <50 yrs compared to men (25% v 10% p=0.0466). The median 240 patients time of presentation was 6.5 months (range 2-36). Deficiency Results: : Over 60% of the patients are enrolled in the study was treated with 200mg Ferrous Sulphate tds for 4months (State 1st February 2010). It is difficult to convince the (median, range 2-8 months).10% of patients required a change patients to become traditional gastric bypass surgery and of formulation. undergoing the randomisation in several centres. The Conclusion: Twenty percent of patients develop iron preliminary observation showed increased BMI reduction after deficiency following LRYGB, particularly in women under BRYGB. the age of 50 years. This may suggest a case for routine Conclusion: There are no reported complications with the therapeutic iron replacement rather than iron supplementation GABP- Ring since the beginning of enrolment. There is in this group. Once iron deficiency developed, 200mg Ferrous reason to suppose that initial postoperative excess weight loss Sulphate tds for four months was sufficient to normalise is enhanced and long-term weight loss maintenance is levels. The median time of presentation was 6.5 months (range improved using the technique of the banded gastric bypass (by 2-36) thus long term follow up and monitoring is essential. avoiding GEA dilation). IHP-023 Mid Jejunal Entrectomy As A Bariatric 2009 by one surgeon. The data was collected and input Procedure prospectively into a bariatric database. Results: 96 (4.6%) patients reported significant bloody or

black stools PRESENTER: Nestor de la Cruz-Munoz (University of 3 (0.14%) were taken to the OR for active bleeding Miami) 6 patients were taken back to the OR for bowel obstruction. Of Co-authors; Juan C. Cabrera1, Melissa Cuesta1, Cristina these, 3 (0.14%) were from abdominal wall hernias and 3 Torres2 (0.14%) were from intraluminal blood clots (none had bloody or black stools prior to the reoperation). 1. Surgery, University of Miami, Doral, FL, United States. In those 3 patients, the anastamosis was opened and the clot 2. Internal Medicine, Bronx Lebenon Hospital Center, Bronx, aspirated. All 3 patients recovered and were discharged home NY, United States. after an average hospital stay of 4 days. Conclusion: Intraluminal bleeding is a relatively commonly Background: Several reports out of Latin America discuss a seen complication after gastric bypass. It is rare for the clots bariatric procedure in which a sleeve gastrectomy, formed to be thick enough to obstruct the intestinal tract, but it omentectomy, and mid small bowel resection have been can occur. One must consider an intraluminal clot as a cause performed with good weight loss results and resolution of of a post operative bowel obstruction. comorbidities. This procedure is reported to avoid the complications of gastric bypass such as vitamin malabsorbtion, dumping syndrome, ulcers and blind, noneasily IHP-025 Laparoscopic Pancreaticoduodenectomy in a endoscopable pieces of bowel. Gastric Bypass Patient Methods: The charts of 2 patients who underwent mid jejunal

Entrectomy under special circumstances were reviewed. PRESENTER: Nestor de la Cruz-Munoz (University of Patient 1 had undergone a gastric bypass complicated by SMV Miami, Doral, FL, United States) thrombosis 10 days later. Her bypass was reversed and the roux limb was excised for ischemia. Patient 2 had her Background: Laparoscopic Pancreaticoduodenectomy (LPD) bypass aborted mid procedure due to severe gastric varices has been described in the literature for over 10 years but has and cirrhosis. The lower anastamosis not gained much acceptance due to the technical difficulty of had been performed, thus, the new Roux limb was excised. the procedure. There are approximately 150 cases described in Results: Patient 1 has lost 59% EBL over 18 months. (BMI the medical literature; a significant percentage of which are from 50.8 to 34.1) She has had complete resolution of her either hand assisted or robotic. We describe the first reported comorbidities. case of a completely LPD in a patient who had previously Patient 2 has lost 37% EBL over 2 months. (BMI 39.5 to 33.3) undergone a laparoscopic gastric bypass (LGBP). She reports improvements in her comorbidities. Methods: Our patient is a 61yo male who had undergone a Both patients report early satiety with meals and the ability to LGBP with a BMI of 42.3 kg/m2. He presented to the office 3 tolerate all types of foods without difficulty. weeks post op with shortness of breath and tachycardia. The Conclusion: Mid jejunal entrectomy has been shown in ensuing workup demonstrated a left pleural effusion and an several studies to promote weight loss. It is theorized that the incidental finding of a poorly defined mass in the head of the early arrival on partialy digested foods may better stimulate pancreas. After appropriate workup, the patient was taken to the terminal ileum to secrete GI hormones (such as GLP-1 surgery for a LPD. and PPY) that cause early satiety and other GI track changes Results: Operative time was 425 min. The gastric remnant was to decrease food intake. Further study into this interesting resected with the whipple specimen. The biliopancreatic limb phenomenon should be conducted. was used for the pancreatic and biliary anastamoses. The resection and reconstruction were both completed laparoscopically. The patient extubated in the OR and spent 18 IHP-024 Blood Clots Are Indeed Thicker Than Water hours in the ICU for observation. He was started on oral fluids on post op day one, and was discharged on post op day four. PRESENTER: Nestor de la Cruz-Munoz (University of He was readmitted on post op day eight for a pancreatic fluid Miami) collection that was drained percutaneously and then closed 1 1 spontaneously. Pathology showed a neuroendocrine tumor Co-authors: Juan C. Cabrera , Melissa Cuesta with negative margins and 11 negative nodes. 1. Surgery, University of Miami, Doral, FL, United States. Conclusion: Although the LPD is a technically difficult procedure, it can be done in patients who have previously

undergone a LGBP. The intestinal changes after gastric bypass Background: Post operative bowel obstruction is a cause of assist in beginning oral intake quickly. The laparoscopic significant post surgical morbidity and mortality. Most approach helps in the rapid recovery postoperatively. obstructions post operatively are due to adhesion formation, technical problems and internal hernias. Obstruction rates after IHP-026 Outcomes Of Bidirectional Stapling Technique bariatric surgery have been reported between 1% and 2% We For A Small Bowel Anastamosis report on a small series of postoperative bowel obstructions due to a different cause. Methods: This is a retrospective review of outcomes from PRESENTER: Nestor de la Cruz-Munoz (University of 2079 gastric bypass procedures performed between 2001and Miami) Co-authors; Juan C. Cabrera1, Melissa Cuesta1 seems logical that an easier procedure should have lower complications than a more difficult one. In our series, the 1. Surgery, University of Miami, Doral, FL, United States. preoperative diet was able to decrease leaks from the Background: Laparoscopic small bowel anastamosis can be gastrojejunal anastamosis technically challenging. Reports have given obstructive complications of 1-2%. Surgeons have tried several techniques to avoid obstruction, including “anti kink” sutures and 2 distal IHP-028 Subcutaneous Unfractionated Heparin For fires to enlarge the opening. Many obstructions occur at the Thromboembolic Prophylaxsis entrance of the afferent limb into the anastamosis upon closure of the enterotomy. The previously described bidirectional PRESENTER: Nestor de la Cruz-Munoz (University of stapling technique moves the enterotomy to the middle of the Miami) anastamosis, theoretically decreasing the chance of an afferent Co-authors: Juan C. Cabrera1, Melissa Cuesta1 limb obstruction. Methods: A retrospective review was performed of 2079 1. Surgery, University of Miami, Doral, FL, United States. laparoscopic gastric bypass procedures. All were performed using the bidirectional stapling technique. The data was Background: The best method of anticoagulation in the inserted prospectively into a bariatric database. Perioperative morbidly obese population undergoing bariatric surgery is still complications were reviewed. not clear. This is a high risk population undergoing a high risk Results: There were 3 intraluminal blood clots causing procedure. Pulmonary embolus is the leading cause of death obstruction, 1 leading to a perforation, for a bariatric patient. Deep venous thrombosis (DVT) has 1 leak due to the staple lines not overlapping (technical error), been reported to occur in approximately 2% of bariatric 1 nearby bowel perforation from grasper trauma, patients, with a pulmonary embolus (PE) occurring in 0.4-1%. 1 return for active bleeding from staple line, It is unclear how to dose patients with such large body mass. Total complications 6 (0.29%) Methods: A retrospective review was performed of 2079 Conclusion: The bidirectional stapling technique for small laparoscopic gastric bypass procedures. All patients received bowel anastamoses is a safe and effective technique and offers the same anticoagulation plan. Sequential compression devices an advantage over the standard technique. It rarely leads to an placed prior to induction and left on while patient was in bed obstruction. Most of the complications seen at the site were or a chair. 5000 units of subcutaneous heparin given in bleeding related, likely due to the anticoaggulation. preholding area and continued every 8 hours until discharge. Patients began ambulation the afternoon after surgery. Patients with previous DVT‟s were sent home on two weeks of 40mg IHP-027 Preoperative Very Low Calorie Diet Can of Lovenox daily. Patients with histories of previous PE‟s also Decrease Gastrojejunal Anastamotic Leaks had a retrievable IVC filter placed preoperatively. Results: There were 5 DVT‟s (0.24%) and 3 PE‟s (0.14%). PRESENTER: Nestor de la Cruz-Munoz (University of Reoperations from bleeding, 3 (0.14%), blood transfusions, 10 Miami) (0.48%) total, 0 intraoperative. Conclusion: Unfractionated herparin, as part of an 1 1 Co-authors: Juan C. Cabrera , Melissa Cuesta anticoaggulation protocol, can be very effective in preventing 1. Surgery, University of Miami, Doral, FL, United States. thromboembolic events. It has a good safety profile, with few adverse side effects. The exact type of heparin used, and its

dose, may have less of a role than we think. Preventing DVT‟s Background: It has been reported that 50% of the gastric likely involves many other factors; including operative time bypass (GBP) cases that are converted to open are due to an and trauma, compression devices and early ambulation. enlarged left lobe of the liver. The liver can make the upper part of the GBP much more difficult to perform. This increased technical difficulty may be a contributing cause of IHP-029 Importance Of A Phone Call Service In The gastrojejunal anastamotic leaks post operatively. It has been Clinical Act reported that a preoperative diet can significantly decrease the size of the liver. There are no reports of complication outcomes after a preoperative diet. Our program began using a PRESENTER: Paula Meireis (Antonio Sergio Clinica) 2 week Optifast diet immediately prior to GBP in July 2007. Co-author: Antonio Sergio1 Methods: A retrospective review of 2079 GBP patients performed by one surgeon form 2001-2009. 704 patients 1. Antonio Sergio Clinica, Oporto, Portugal. underwent the procedure after a preoperative diet. This group was compared to the previous 704 patients who had not Background: Several studies have reported the crucial followed a preop diet (thus avoiding the surgeon learning importance of long-term follow-up after adjustable gastric curve). The number of gastrojejunal leaks in each group were banding. The patient need to be supported and motivated to calculated. participate in a long term program, and adopt new lifestyles. Results: The non diet group had 5 leaks (0.7%) while the diet Patient and team must be prepared for this commitment, as a group has had 0 leaks. (p=0.03) long trip they will do together. Conclusion: Using a preoperative diet to decrease left liver Methods: In pre-operative time, patient should be instructed size can make the procedure technically easier to perform. It concerning: changes in eating habits, physical activity, risk behaviors, signs and symptoms of complications; this support Carlos Altamirano1 and patient responsibility must continue after surgery. 1. Surgery , Hospital Angeles Lomas, Mexico City, Mexico. Hospital stay‟s short, first days at home are fundamental to early identification and resolution of complications. A phone call is made by a nurse experienced in bariatric Background: Purpose: Show the results of conversion to LSG surgery, using an assessment algorithm. First phone call is when an AGB has failed. made 24h after discharge and second phone call 72h after Methods: Materials and Methods: All patients who required discharge, than intervals are according to patient needs. In this AGB removal due to failure, dysfunction or dissatisfaction and phone call next points are raised: general status, check for who agreed to undergo LSG as an alternative bariatric signs of infection, other complications (pulmonary procedure were analyzed. Variables included BMI at the time tromboembolism), pain control, diet maladjustment and return of LSG and at the longest follow-up for each patient, surgical to physical activity. and postoperative complications. All patients were surveyed in Results: Patient feels supported and his connection to the team terms of procedure preference, postoperative adaptation, and grows, at the same time patient feels he is called to participate feeding compliance comparing each of the two procedures in the therapeutic process. Small doubts and big problems can performed. be eliminated or minimize. Results: Ten patients were evaluated. Mean age was 38 years Conclusion: Gastric banding results are optimized; (range 26-58). BMI before the initial AGB procedure ranged complications are minimized by its early identification. Patient from 35-44. We had no complications nor mortality in this feels more supported and his loyalty to the team is improved, series. Average time with the AGB was 5 yrs (range 3-7). BMI he become more participative. average at the time of LSG was 31 (range 22-40). Average follow-up after LSG was 6 months (range 1-15 months). Last BMI assay after LSG averaged 30 (25-39), no patient regained IHP-030 Pre-Operative Cardio Pulmonary Exercise weight. All patients considered both procedures as successful Testing in Bariatric Surgery in terms of weight loss but also agreed to have had better postoperative adaptation, food compliance and preference for

LSG when compared to AGB. Most would recommend the PRESENTER: Dugal Heath (Whittington Hospital) LSG as the procedure of choice. Co-authors: Sufi Pratik1, Krzysztof Halas1, Philip Hennis1, Conclusion: Conversion of an AGB to a LSG is feasible and Paula Meale1 safe with acceptable outcome, and offers the possibility to maintain weight loss. Patient satisfaction with the LSG seems 1. Bariatric surgery, Whittington Hospital, London, uk, United to be better than with the AGB. Further studies are required to Kingdom. assess the usefulness of LSG in cases in which AGB has failed. Background: Cardiac disease are risk factors for post- operative morbidity and mortality after bariatric surgery. Pre operative testing offers a possibility of identifying this subset IHP-032 An Alternate Model Of Care For A Bariatric of patients. It has been suggested that anaerobic threshold Clinic In Australia (AT) of < 11 in Cardio-Pulmonary Exercise Test (CPEX) predicts increased risk of peri-operative complications. The PRESENTER: Narelle Story (Australian Bariatric pilot study aimed examine the value of CPEX in predicting Nursing, Sydney, NSW, Australia) peri-operative complications in bariatric surgery. Methods: Data was collected prospectively for 52 consecutive Background: Most bariatric models of care world wide are patients who underwent pre-operative CPEX before bariatric predominantly led by surgeons with a concomittant emphasis surgery - laparoscopic gastric bypass was performed in 95%. on the surgical component. Bariatric treatment and care All patients had post operative HDU care. Peri-operative delivery is viewed in the context of "the surgical solution" for morbidity data was collected. morbid obesity. This paper will describe an alternate model of Results: CPEX identified 48% of patients with AT < 11. long term bariatric care for gastric band patients. It is akin to a POSSUM predicted morbidity for patients with AT < 11 was chronic disease model where surgeons are members of an 33.7% and for those with AT > 11 was 33.2%. There was no integrated team. mortality and the observed morbidity was similar (2 patients in Methods: This model emerged after the clinic first opened its each group) in both groups. doors in 2004. Since that time, over 1200 patients have been Conclusion: In this pilot study, AT < 11 at pre-operative seen for primary surgery and long term follow up care with CPEX testing was not successful in identifying patients who many more patients presenting for their long term care who were at higher risk of post operative complications. have had surgery elsewhere. The team consists of multiple surgeons (up to 7 at one time),physicians, dietitians, a psychologist, a registered nurse, and administration team IHP-031 Laparoscopic Sleeve Gastrectomy (LSG): A members. No one person is more vital than the whole. Surgery Useful Alternative To Failed Gastric Banding (AGB). for band insertion is viewed not as insignificant, but nonetheless it is one intervention on one hour of one day. The PRESENTER: Alejandro Weber (Hospital Angeles band whilst placed creating a vitual pouch, is philosophically Lomas) situated around the brain, not the stomach. This is not a restrictive procedure and as such each member of the bariatric Co-authors: Felipe Vega1, Denzil Garteiz1, Rafael Carbó1, team has a complimentary role to play with each contributing to support, educate and teach the patient how to use and manage this new tool. These and further differences to conventional clinic models are explored in this paper. Results: In terms of clinical outcomes, an average excess weight loss of 52% over 5 years is reported. Complication rates are comparable to worldwide outcomes, being less than 10% for all types with reoperation rates less than 9%.

Conclusion: In the bariatric world, alternate models of care do exist with respectable and comparable weight loss outcomes and complication rates.

IHP-033 A Statistical Analysis of a Clinic’s Pre-operative Bariatric Population: A Composite View of Male and Female Morbid Obesity PRESENTER: Stephen Wohlgemuth (Sentara Hospital System) Co-author: David B. Stefan1 1. Novaptus Systems, Inc, Chesapeake, VA, United States. 2. Metabolic and Weight Loss Surgery Center, Sentara Hospital System, Norfolk, VA, United States. The composite image of 500 female bariatric patients Background: Since 2007, all bariatric subjects enrolling in the recreated by the scanner software bariatric surgery program at Sentara Hospital System‟s Metabolic and Weight Loss Surgery Center have been scanned and measured by a 3D whole-body scanning system. This is done as a service to the subject to profile their pre-operative measurements and current body habitus. The tremendous amount of measurements collected from each scan was couple with height, weight and other pertinent medical information and compiled to form a statistical composite view of the male and female pre-operative bariatric subject. Methods: A total of 600 pre-operative bariatric subjects were scanned between mid-2007 and the end of 2009. This group contained 500 female and 100 male subjects. Once scanned, a measurement profile was applied to the subject‟s 3D body model. Measurements were automatically extracted and tabulated. Weight, height, BMI and co-morbidities were also recorded. A statistical analysis was performed. Results: The analysis yielded interesting results. The average weight for the female bariatric subject was 266 lbs and she was 5‟6” tall with a BMI of 49. Her waist was 47”, hips 54” and bust 52”. She exhibited an average of 2.5 of the 4 co- morbidities. Other measurements such as thigh, bicep and neck were compiled as well. The average weight for the male was 288 lbs and he was 5‟10” tall with a BMI of 52. His waist was 52”, chest 54”, etc. Conclusion: By combining the vast information provided by the scanner, along with height, weight and co-morbidity information, a clear composite view of the average male and Composite view of 100 males based on statistical analysis female bariatric subject was created. This information was fed back into the scanner to create a 3D body model for the average male and female subject. Further analysis divided this information based on race aspects.