6Th World Congress of the International Federation for The

Obesity Surgery, 11, 345-349 P R O G R A M 6th World Congress of the International Federation for the Surgery of Obesity (IFSO) 3rd International Symposium on Laparoscopic Obesity Surgery (ISLOS) 15th International Symposium on Obesity Surgery September 5-8th, 2001, Chania, Crete, Greece

IFSO Organized by the Greek Society President: Andrew C.Jamieson for Bariatric Surgery Executive Director: Mervyn Deitel Organizing Secretariat: Past President :Emanuel Hell Mrs. Christina Kotsaki, President Elect: Martin Fried University General Hospital, Vice President: Aniceto Baltasar P.O.Box 1352, Secretary Treasurer: Arthur B.Garrido, Jr. Heraklion 71110, Honorary President: Nicola Scopinaro Crete, Greece Board of Trustees: George S.M.Cowan, Jr. Tel: +30-81-392387; Fax: +30-81-542090 MESSAGE FROM THE PRESIDENT OF THE 6th WORLDCONGRESS Crete was the cradle of the Minoan Civilization (2700-1100 BC), considered to be the most advanced ancient civilization in Europe. Religious, Magic and Empirical Medicine as well as Elementary Surgery and Dentistry were practiced during the Minoan period. Cretan therapists were using herbs as pharmaceutical agents to alle- viate war injuries and facilitate deliveries. In Crete one can find two of the most famous “Asclepeion" of Ancient Greece—that of Lebena in the South of the island and that of Lissos the west part of Crete. Patients from all over Crete, but also from Southern Greece and North Africa, were traveling to those Ancient Clinics to seek medical attention. Dear Friends, I have the pleasure and the honor to invite you to the 6th World Congress of IFSO on the island of Crete with its remarkable history of Medicine. The Congress will take place in the city of Chania, the second biggest but most beautiful town in Crete. The weather during September is ideal to combine scientific engagement with holidays and enjoy the beach, the natural beauties and the archaeological sights of the island. During the Congress we will discuss all major issues related to antiobesity surgery.Leading experts from all over the world will be there to present their valuable experience. Two major conference rooms will be available for the oral presentation and the video sessions, and there will be a poster and medical exhibition. The Congress will take place in the Orthodox Academy of Crete, in Kolimbari, a village situated about 22 km from Chania, in the foot of a mountain and near the sea, where no one can disturb the stillness and quietness of the place. The welcome reception will take place in the port of the old town with the fantastic view of the Venetian light- house. A farewell Cretan night is also scheduled. I hope that everyone will have the opportunity to meet old friends here and make new ones. I look forward to welcoming you in Crete. John Melissas President of the Congress

©FD-Communications Inc. Obesity Surgery,11, 2001 345 BRING THIS PROGRAM ISSUE WITH YOU TO CRETE The IFSO program portion with the abstracts in this issue is sponsored by BioEnterics Corporation

GENERAL INFORMA TION Venue Orthodox Academy of Crete, Chania Crete, Greece, September 5-8, 2001. A bus shuttle service will provide connection with the congress hotels.

Official Language: English Currency Greek Drachmas (GRD) Exchange rates:1 U.S.$ ±400 Grd (indicative;check with your bank for current rate), 1 Euro ±340 Grd. Credit Cards—Exchange Credit Cards are widely accepted at department stores, shops, restaurants and nightclubs. Currency can be exchanged at your hotel, travel agent or other tourist offices operating in the city, as well as banks. Insurance The Organizers cannot accept responsibility for accidents which might occur.Delegates are encouraged to obtain travel insurance (medical, personal accident, and luggage), in their home country. Electrical Appliances Greece operates on 220 volts for electrical appliances. The frequency is 50Hz. Bank—Shops The business hour of most department stores are from 08.30 to 20.30. They are open on weekdays and Saturdays but closed on Sundays and National holidays. Banks are open from 08.00-2.00 on Mondays, Tuesdays, Wednesdays and Thursdays from 08.00 to 01.30 on Fridays. Transportation Buses are available for nearly all destinations from Chania. If you need a taxi from Congress Hotels, please call 98700 and 87700 (use 0821 when calling from a mobile phone, followed by the telephone number). From the Conference Hall call a taxi at (0824) 23322.22230.22140 or 22333. Useful telephones: Chania General Hospital: (0821) 22000, Police 100, Airport:(0821) 63224. Weather and Clothing The weather in Crete is ideal during September. It is neither too hot nor windy and autumn is still far to come. Rain is extremely unusual for this time of the year in Chania. Sea water is ideal for swimming. Day temperature ranges from 24o to 32oC (75o - 89o F).Nevertheless, you could bring a sweater with you in case of chilly nights. How to get to Chania You can reach Chania by two different means of transportation:) by plane (preferably) and by boat. There are flights every day from Athens by Olympic Airways, Aegean Airlines and Cronus Airlines.The trip lasts approximately 40 min. Taxi fare from the airport to the Congress Hotels and/or to the Conference Hall is about Grd 8.000-10.000, depending on the distance.However, a welcome desk will be set at Chania Airport by the organizers, during the Meeting, and transportation from the Airport to the Hotel of your choice and to the Conference Hall and vice versa can be pre- arranged for those interested in this service. Website: http://www.obesity-online.com/ifso 2001 SOCIAL PROGRAM Wednesday September 5: Welcome Reception at Chania in the port of the Old Town,after the opening ceremony (cocktail and buffet dinner)Bus transfer from the Congress Hotels. Friday September 7 evening: Gala dinner, Cretan night with traditional Greek cuisine.Bus transfer from the Congress Hotels.

346 Obesity Surgery,11, 2001 IMPORTANT DATES

September 5 0900-1200 hrs — Allied Health Session 1300-1730 hrs — 3rd ISLOS 2000 hrs — Welcome Reception and Buffet in the port of the Old Town of Chania September 6-8 6th World Congress of IFSO, 15th International Symposium on Obesity Surgery September 7 2030 hrs.— Gala Dinner, “Metoxi”Restaurant, Cretan night and cuisine

CONGRESS OPTIONAL TOURS

1. City Tour of Chania: Visit to the town’s most beautiful spots and sights.The Cathedral, the historic Monastery of St.T riada, the Hamam, the Arsenal, the Public Market and the Synagogue are only few of the sites you will be seeing. Price:11.000 GRD Wed., Sept. 5; 0800-1400 hrs.

2. Samaria Gorge (lazy way): Enjoy the unique scenery of the longest gorge in Europe, and a swim in the crystal waters of the Libyan Sea. Visit to “Sfakia”village where the gorge comes to an end. Then an easy walk of about one hour will allow you to see a big part of the Gorge. Price:15.000 GRD (entrance fees and boat are included). Thurs., Sept. 6 (lazy way);0700-1600 hrs.

3. Knossos—Archaeological Museum of Heraklion: Experience power and the vitality of the era of the worldwide known Minoan civilization and witness the complexity of the Minoans’lifestyle. Visit one of the most important museums in the world where original pieces from the Neolithic, Minoan and Greco-Roman periods are exposed. Price:18.500 GRD (entrance fees to Knossos and the museum are included). Fri., Sept. 7; 0700-1600 hrs.

POST-CONGRESS TOURS*

1. Samaria Gorge: Experience the stunning drive through the White Mountains to the Plateau of Omalos, the unspoilt scenery, rare flora and the caves on the rugged mountain sides as well as the rare goat “Kri-Kri”. Price:14.500 GRD

2. Santorini: Magical trip to an island of exceptional geological structure, which is the result of the eruptions of an now inactive volcano. You will visit ancient “Thira”, you willl see the most beautiful sunset in “Oia”, you will swim in the crystal waters of the warm sea and sunbathe on the red and black beaches with shingle. Price:32.000 GRD (includes:transfers, boat fares, one night stay in **Hotel, excurison with guide).

3. Cretan Villages Tour: During this you will visit the Red Village where you will have the chance to see the procedure of making Physic Glass.The next stop will be “Argyroupoli”town where you will see the natural waterfalls, and after that the beautiful lae of “Kournas”and the village of “Vrisses”known for its honey and cheese products.Lastly , you will experience the original procedure of winemaking in a local winery. Price:12.500 GRD

4. Elafonissi: A tour of one of the most beautiful places in Crete, an island on the southwestern part of Crete. The coralline sand and the magnificent scenery offer the visitor a very special experience. On the way to Elafonissi you will stop at Elos village, a place full of chestnut trees, and at the Chrissoskalitissa Monastery.On the way back to Chania you will visit the church of St.Sofia which is built in a cave with stalactites and stalagmites. Price:10.600 GRD.

* Post-Congress Tours will be arranged during the Meeting .Please contact the Congress Secretariat for inquiries and to make all the necessary arrangements.

Obesity Surgery,11, 2001 347 CONGRESS The congress will consist of plenary sessions and a permanent poster exhibit. An Award for the best Poster will be given. Presentations will be oral and/or video. The Authors will be given a presentation time, and they will be free of sharing between the oral and video part, without in any case exceeding the total time assigned . The 3rd ISLOS will deal with novelties in laparoscopic obesity surgery and technical aspects.

Slide Presentation: Standard 35 mm slide projection (single or double). Computer Presentation: Preferably with own PClaptop, otherwise use MS PowerPoint for Windows 98/00. Video Presentation: VHS and all other programs available (Pal, Secam, NTSC). Poster Instructions: Poster must be prepared to fit a board of 135 cm height and 90 cm width.

CONGRESS REGISTRATION FORM

Check Before April 30, 2001 After April 30, 2001 IFSO Member* Grd 150.000 170.000 Non-IFSO Member* 170.000 190.000 Allied Care Professional** 60.000 65.000 3rd ISLOS alone*** 30.000 35.000 Accompanying Person**** 60.000 65.000 Extra ticket for Gala Dinner 25.000 30.000 T ourA - Knossos and Archeological Museum 18.500 Tour B - Samaria Gorge 15.000 Tour C - Chania City Tour 11.000 Total Amount Due *IFSO Membership entails subscription to the Journal OBESITY SURGERY .

*Includes 3 rd ISLOS, coffee breaks, lunches, Welcome Reception and Gala Dinner. **Special reduced fee, includes 3 rd ISLOS, coffee breaks, lunches, Welcome Reception. *** Includes Welcome Reception. ****Includes Welcome Reception and Gala Dinner.

Cancellation until August 15: secretariat charge Grd 15.000; thereafter, no refund. Name______Address______City______Postal Code______Country______Tel______Fax______E-mail______

[]Credit Card Visa______Eurocard/Mastercard______American Express______Card no.______Expiry date______Name of the card holder______Signature______

[]Bank transfer to:Mrs. Christina Kotsaki, Agricultural Bank of Greece, Bank Account No. 366 01 103 698 71, Swift code 1110 (copy enclosed). Send to:Mrs Christina Kotsaki University General Hospital P.O Box 1352 Heraklion 71110, Crete, GREECE Tel:+30 81 392387; fax:+ 30 81 542090; e-mail:[email protected] Presenters must register for the Meeting by the abstract deadline of May 1,2001.

348 Obesity Surgery,11, 2001 6th Congress of the International Federation for the Surgery of Obesity 15th International Symposium on Obesity Surgery 3rd International Symposium on Laparoscopic Obesity Surgery September 5-8, 2001 Chania Crete Greece

HOTEL RESERVATION FORM Hotel Rooms Rates per room No. of Arrival date No. of Including breakfast rooms nights Panorama Double sea view *GRD 52.000 Double mountain view 49.000 Double/single occupancy 46.000 Creta Paradise Single sea view 40.000 Single mountain view 36.000 Double sea view 46.000 Double mountain view 41.000 Bungalow 52.000 Aegean Palace Single 39.000 Double 44.000 Suite, private swimming pool 65.000 Santa Marina Single mountain view 24.000 Double sea view 34.000 Double mountain view 28.000 Chrispy Single 23.000 Double 27.000 Double/single occupancy 25.000

*GRD= Greek Drachmas,1US $= ±400 GRD, 1 EURO= ±340 GRD (indicative rate) Prices include all rates and taxes. Child 0-2 years old free. 3rd person in double room 30% addition. A written confirmation will be sent upon receipt of the reservation form. September in Chania is a very busy tourist period. A consistent number of rooms have been booked at the hotels listed above for the Congress. Nevertheless since the number of participants is unforeseeable,early hotel reservation is strongly recommended (before May 31st,2001). In case the hotel of choice is fully sold out,an alternative will be offered and reservation will be made only after approval. Due to the limited number of the single rooms,they will be assigned on a first come,first served basis. Reservation requests must be accompanied with a two nights room deposit by bank transfer or credit card. Cancellation policy:to May 31st total refund,between June 1st and July 31st one night refund,after August 1st no refund.

Name______Address______City______PostalCode______Country______Tel______Fax______E-mail______

[]Credit Card Visa______Eurocard/Mastercard______American Express______Card no.______Expiry date______Name of the card holder______Signature______

[]Bank transfer to:Mrs. Christina Kotsaki, Agricultural Bank of Greece, Bank Account No. 366 01 103 698 71, Swift code 1110 ( copy enclosed ).

Send to:Mrs.Christina Kotsaki University General Hospital P.O.Box 1352 Heraklion 71 110, Crete, GREECE Tel:+30 81 392387; fax:+ 30 81 542090; e-mail:[email protected]

Obesity Surgery,11, 2001 349 Obesity Surgery, 11, 351-374 SCIENTIFIC PROGRAM

Wednesday,September 5, 2001 ALLIED HEALTH SESSION IPPOCRATES HALL

Session 1

Moderators: Nancy Mead, Greece; Mary-Lou Walen, U. S.A.

09:00 1. Obesity Surgery: Utility of psychological area in multidiscipli nary team and future challenges. Susana Bayardo, RN .Instituto Multidisciplinario Especializado en el tratamiento y cirugia de la Obesidad, Argentina. 09:12 2. Continuing Education, Our Responsibility to T each Lessons of the Body,Bones and Brains. Jacquelyn K.Smiertka, RN .Bloomfield Bariatrics-Private Practice, Michigan, U.S.A. 09:24 3. The “INFO G”group: a Support Team for the Obese Patient. Christian A.G. Thyse, RN .Centre Hospitalier Régional de Huy, Huy, Belgium. 09:36 4. Preliminary survey of sexual orientation after weight loss surgery in homosexual females. Delphine Nuglozeh-Buck, RN, Barbara Metcalf, RN, William Harman, Ph.D, Gregg H.Jossart, MD, Robert A.Rabkin, MD. Pacific Laparoscopy, San Francisco, CA, U.S.A. 09:48 5. Pregnancy after Gastric Bypass. Bobbie Lou Tripp, RN, Melvin S. Swanson, PhD, Paul Cunningham, MD, Walter Pories, MD , Sharon Ripley, RN, Bret Brown, RHIA, Kenneth MacDonald, MD.Brody School of Medicine, East Carolina University, Greenville, NC, U.S.A.

Session 2

Moderators: Tracy Owens, U. S.A.;Christian A.G.Thyse, Belgium

10:00 6. Pre and Postoperative Protocol for Bariatric Surgical Patients. Aggeliki Loukidi , Nancy Mead, Fotis Kalfarentzos, MD. Nutrition Support and Morbid Obesity Clinic, Surgical Department, University Hospital of Patras, Greece. 10:12 7. Dietary Management of Patients with Morbid Obesity after Vertical Banded Gastroplasty. Vassiliki Komessidou, A.Papakonstantinou, P.Alfaras, I. Terzis, P .Moustafellos, S. Gourgiotis, S.Brousta, E. Hatjiyannakis.Depar tment of Nutrition and 1st Depar tment of Surger y, “Evangelismos”General Hospital, Athens, Greece. 10:24 8. Coping Style and Eating Pattern in Obese and Morbidly Obese Patients who were Screened Preoperatively for a Gastric Restriction Procedure. Rogier Horchner, MSc, RN, Wim T uinebreijer, MD, PhD, MSc.Department of Clinical Research Ra-Medic & Dutch Obesity Clinic, Hilversum, The Netherlands. 10:36 9. Anesthetic Care in Morbid Obesity. Adrian Alvarez, Antonio Jose Cascardo, Silvio Albarracin. IMETCO (Multidisciplinary Institute

©FD-Communications Inc. Obesity Surgery,11, 2001 351 Crete Program Specialized in the Treatment and the Surgery of Obesity), Buenos Aires, Argentina. 10:48 10. Bariatric Operation in a Patient with Possible Psychiatric Contraindication - Case Report. A.P.Azevedo, H.T.Libanori, A.Segal. Institute of Psychiatry , Hospital das Clinicas, Sao Paolo University Medical School, Sao Paolo, Brazil.

Session 3

Moderators: Elisabeth-Ardelt Gattinger, Austria; Kathy Fox, U. S.A.

11:00 11. Addictions? Role after Bariatric Surgery. Elisabeth Ardelt-Gattinger, Irene Hofmann, Edda Angermann, Melodie Moorehead. Psychological Institute of University of Salzburg Austria;Holy Cross Hospital, Ft.Lauderdale, FL, U. S.A.. 11:12 12. A 15-year Evaluation of BPD Results According to BAROS Criteria. Giuseppe M. Marinari, Giovanni Camerini, Federica Murelli, Francesco Papadia, Paola Marini, Cesare Stabilini, Flavia Carlini, Nicola Scopinaro. DICMI, Semeiotica Chirurgica R, University of Genoa School of Medicine, Genoa, Italy. 11:24 13. Preoperative Behavioral-Cognitive Psychotherapy for Bariatric Surgery Patients. A.Mingardi, G.Crozeta, M.A. Larino, H.T.Libanori, A.Segal. Institute of Psychiatry , Hospital das Clinicas, Sao Paolo University, Medical School, Sao Paolo, Brazil. 11:36 14. Psychological factors and patient motives in relation to BMI reduction in morbidly obese patients following bariatric surgery. Ioannis Vlachos O.** , Theofilos Stergiou**, Nancy Mead*, Stavroula Berati**, Fotis Kalfarentzos*.Nutrition Support and Morbid Obesity Clinic, Surgical Department* and Psychiatric Department**, University Hospital of Patras, Greece. 11:48 15. The Effects of Gastric Bypass Surgery on Measures of Psychological Distress. Mary Gallacher, M.B., Ch.B., Cynthia Buffington, Ph.D., George S.M. Cowan, Jr., M.D. The University of T ennessee Health Science Center, Department of Surgery and The Clinical Research Center, Memphis, Tennessee, U.S.A.

12:00 LUNCH (Allied Health Science Group Luncheon Meeting).

Wednesday,September 5, 2001 3rd International Symposium on Laparoscopic Obesity Surgery (ISLOS) IPPOCRATES HALL

Session 1

Gastric Banding: Surgical Techniques.

Moderators: Carlos A.Casalnuovo, Argentina; Eliezer Avinoah, Israel

13:00 16. Lap-Band, Changes in Surgical Technique: Outcome of 1410 Surgeries Performed from July 1995 through April 2001. Jean-Marie Zimmermann , Michel Blanc, Pierre Mashoyan, Érick Zimmermann, Jean-Marc

352 Obesity Surgery,11, 2001 Crete Program Grimaldi. Clairval Private Hospital Center, Marseille, France. 13:12 17. Proximal Gastric Banding after Failed Gastric Restrictive Operations. Eliezer Avinoah, Solly Mizrahi, Leonid Landsberg. Surgery A, Soroka Medical Center, Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel. 13:24 18. Technical Modification in Lap-Band Implant. Carlos Alberto Casalnuovo, Ezequiel Ochoa de Eguileor, Gustavo Parrilla, Marco More. Hospital de Clínicas, University of Buenos Aires, and Private Practice (CCO-Centro de Cirugía de la Obesidad), Buenos Aires, Argentina. 13:36 19. LAP-BAND Gastric Banding in a Public University Hospital: Success and Pitfalls with 450 Patients in Four years. Jean-Marc Chevalier , Franck Zinzindohoue, Jean-Philippe Blanche, Richard Douard, Jean Louis Berta, Jean Jacques Altman, Paul-Henri Cugnenc. Departments of Surgery and Nutrition.Hô pital Europpéen Georges Pompidou, Paris, France. 13:48 20. Laparoscopic Gastric Banding: Why Changing To Another Technique? Ahmed Zayed, Mohammad Al-Jarallah.Armed Forces Hospital Kuwait, State of Kuwait.

Session 2

Special Lectures

Moderators: Ingmar Näslund, Sweden; Pierre Urbain, Belgium 14:00-14:30 Initial Results and Possible Mechanisms of Gastric Pacing Robert Greenstein, U. S.A. 14:30-15:00 A Standardized Reproducible Approach for Laparoscopic Vertical Banded Gastroplasty Jean-Luis Allé, Belgium.

15:00-15:30 COFFEE BREAK

Session 3

Laparoscopic VBG

Moderators: Häns Lönroth, Sweden; Mauro Toppino, Italy

15:30 21. Modified Laparoscopic VBG for Treatment of Morbidly Obese Patients. John Melissas ,George Schoretsanitis , John Grammatikakis, Demetrios Michaloudis, Demetrios D. Tsiftsis.Bariatric Unit, Dept. Surgical Oncology, University Hospital, Heraklion, Crete, Greece. 15:42 22. Laparoscopic Vertical Banded Gastroplasty (VBG) – Long-Term Outcome in 139 Patients. Torsten Olbers, Hans Lönroth, Jan Dalenbäck*, Eva Haglind, Lars Lundell. Department of Upper G.I Surgery, Sahlgrenska University Hospital and *Frolunda Specialist Hospital, Gothenburg, Sweden. 15:54 23. Laparoscopic Vertical Banded Gastroplasty: Results in 250 Cases with 5-years Follow–Up. Mauro Toppino, Mario Morino, Danilo Donati, Luca Mazza, V aleria Costamagna. Department of Surgery, University of Turin, Italy. 16:06 24. Laparoscopic Vertical Banded Gastroplasty with Adjustable Band in the Treatment of Morbid Obesity. Giovanni Natalini, Francesco Guiggi, Luca Calzoni. Department of Surgery, Marsciano-Todi Hospital,

Obesity Surgery,11, 2001 353 Crete Program Marsciano, Italy. 16:18 25. Laparoscopic Long Vertical Gastric Stapling ±Sleeve Gastrectomy for the Treatment of Morbid Obesity. Simon P.L. Dexter, Michael J.McMahon, Nikos Georgopoulos. Leeds Institute for Minimally Invasive Therapy, The General Infirmary, Leeds, UK.

Session 4 Laparoscopic Gastric Bypass

Moderators: Luigi Angrisani, Italy;Arthur B.Garrido Jr,Brazil

16:30 26. The Gagner Technique for Laparoscopic Gastric Bypass: Technical Observations and Details. (Video) Luigi Angrisani, Michele Maresca, Vincenzo Borrelli, Gaetano Cimmino, Monica Ciannella. Unit of Endoscopic Surgery, “S. Giovanni Bosco”Hospital, Naples, Italy. 16:42 27. Laparoscopic Roux-en Y Gastric Bypass with Silastic Ring (Capella’s procedure) in the Treatment of Morbid Obesity: Technical Description in Video. Thomas Szegö, Arthur B. Garrido Jr, Mitsunori Matsuda, Carlos José Lazzarini Mendes, Marcelo Roque de Oliveira, Alexander Elias, Luiz Vicente Berti.Private Practice, Albert Einstein and Beneficência Portuguesa Hospital, São Paolo, Brazil. 16:54 28. Laparoscopic Isolated Roux-en-Y Gastric Bypass: Preliminary Experience. A.Restuccia, D. Polito, G.Silecchia, A.Genco, U. Elmore, N.Perrotta, F.Greco, P.Fabiano, N.Basso. Dipartimento di Chirurgia “Paride Stefanini”, Policlinico “ Umberto l’Università ”La Sapienza”, Roma, Italy. 17:06 29. Laparoscopic Roux-en-Y Gastric Bypass - Evaluation of Three Different Techniques. Essam Abdel Galil, Alla Abbass Sabry**.Department of Surgery, Ahmed Maher Teaching Hospital* and Ain Shams University**, Cairo, Egypt. 17:18 30. Functional Gastric Bypass. Francesco Furbetta , G.Gambinotti. Ospedale di Pescia, Pescia, PT, Italy.

20:00 Bus Transfer From Hotels to Chania. 20:30 Opening Ceremony – Chania Port of Old Town. 21:00 Welcome Reception, Cocktail and Buffet Dinner (Port of Old Town). 23:30 Bus Transfer from Chania to Hotels.

354 Obesity Surgery,11, 2001 Crete Program

Wednesday,September 5, 2001

3rd ISLOS (Concurrent Session) SAINT LUCAS HALL

Session 1

Gastric Bypass

Moderators: Scott A.Shikora, U.S.A.;Guiseppe Marinari,Italy

13:00 31. A Comparative Study in Percentage of Weight Loss Between Laparoscopic and Open Roux-en-Y Gastric Bypass. Constantine P.Spanos, Edward Salzmann, Christa M.Triglio PA-C, Scott A.Shikora. New England Medical Center, Boston, MA, U.S.A. 13:12 32. Retrospective Comparison of Laparoscopic versus Open Gastric Bypass for Morbid Obesity. Anna Uskova, George Bentzel , Devora Hathaway BSN, Daniel Gagne, Raye Budway, Robert Quinlan, Philip Caushaj. Department of Surgery , Temple University School of Medicine Clinical Campus at the Western Pennsylvania Hospital, Pittsburgh, Pennsylvania, U.S.A. 13:24 33. Laparoscopic Reoperation for Early Complications of Laparoscopic Gastric Bypass. P.Papasavas, M.S.O’ Mara, D. Heathaway, P.F.Caushaj, D.Gagne. Department of Surgery , The Western Pennsylvania Hospital, Temple University Clinical Campus, Pittsburgh, Pennsylvania, U.S.A. 13:36 34. The Art of Recycling: Laparoscopic Ventral Hernia Repair after Open Roux-en-Y Gastric Bypass. Marina S. Kurian, Daniel Marcus, Mitchell S. Roslin.Department of Surgery, Lenox Hill Hospital, New York, NY, U.S.A. 13:48 35. Laparoscopic Ventral Hernia Repair In Morbidly Obese after Open Roux-en-Y Gastric Bypass. Piotr J. Gorecki, L.D.George Angus. Nassau University Medical Center, East Meadow, NY, U.S.A.

Session 2

Laparoscopic Restrictive Procedures

Moderators: Franz Aigner, Austria; Harry Frydenberg, Australia

14:00 36. Laparoscopic Adjustable Gastric Banding in Highly Obese. F.Aigner, H.Weiss, H.Nehoda, H.Bonnati. University Hospital of Surgery, Department of General Surgery, Innsbruck, Austria. 14:12 37. Our Initial Steps in Laparoscopic Bariatric Surgery. J.Bende, M.Ursu, M.Csiszár. Pé terfy Hospital, Department of Surgery, Budapest, Hungary. 14:24 38. Band Erosion and Slippage: Detecting and Avoiding Long-Term Complications. J.A. Lopez Corvala, F .Cordero Guzman, A.A.A. Ortiz Lagardere. Laparoscopic Group of Baja California, OBCT Control Center, Tijuana, Mexico. 14:36 39. Use of BioEnterics Intragastric Balloon System for Obesity Treatment. L.J.D.M.Schelfhout, J.Scherpenisse. Medical Centre Rotterdam Airport, D.Gabriels-Verweyen Body Services Medical Centre Rotterdam Airport, The Netherlands.

Obesity Surgery,11, 2001 355 Crete Program 14:48 40. 5-year Results of Laparoscopic Gastric Banding for Morbid Obesity. M. K Müller1, M. Weber1, O. Schob2, L.Krähenbü hl 1, R.Schlumpf 3, R.S.Hauser 4. 1. University Hospital Zürich, Surgery; 2. Spital Limmattal, Visceral Surgery Schlieren; 3. Kantonspital Aarau, Department of Surgery, Aarau; 4. Consultant for Nutrition, Zürich, Switzerland.

15:00-15:30 COFFEE BREAK

Session 3

Morbid Obesity: Management Options

Moderators: Jean-Marie Zimmerman, France; Jan Willem Greve, The Netherlands

15:30 41. Swedish Adjustable Gastric Band - Reoperation and Erosion. Antelmo Sasso Fin .Hospital São Luiz, Brazil. 15:42 42. Lap-Band and Hiatus Hernia. Francesco Furbetta, G.Gambinotti. Ospedale di Pescia, Pescia, PT, Italy. 15:54 43. Preliminary Results after Combination of using the HELIOGAST Band and the Two Step Technique to Prevent Complications of the Laparoscopic Gastric Banding. Salomon Benchetrit. Clinique Jeanne d’Arc, Service de chirurgie digestive.Lyon, France. 16:06 44. Swedish Adjustable Gastric Banding in Morbidly Obese: Three years Experience. Hany Aly Nowara .Cairo University Hospital and Mokattam Surgery Center, Egypt. 16:18 45. Laparoscopic Vertical Banded Gastroplasty and Roux-en-Y Gastric Bypass: Two Years Experience. F.Cruz, J.L.Cruz, J.Canga, P.Gómez, J.I.Martí nez, J.M.Mené ndez, P.Yuste, P.Villarejo, E.Pérez, J.Moradiellos. 12 de Octubre University Hospital (Madrid); León Hospital (León).

Session 4

Long-Term Evaluation of Gastric Banding

Moderators: Marc Vertruyen, Belgium; Karl Miller,Austria

16:30 46. Esophageal Dilation After Laparoscopic Adjustable Gastric Banding: Myth or Reality? Justin R.de Jong* , Cas H.J. Tiethof**, Robin Timmer***, Andre J.P.M.Smout****, Bert van Ramshorst*.Depts. of Surgery*, Radiology** and Gastroenterology***, St. Antonius Hospital Nieuwegein, Dept. of Gastroenterology**** University Medical Centre Utrecht, The Netherlands. 16:42 47. Re-operations Following LASGB. Ralph Peterli, Andrea Donadini, Peter Tondelli. Surgical Clinic, St.Claraspital Basel, Switzerland. 16:54 48. Evaluation of 150 patients with Laparoscopic Adjustable Gastric Banding. Carlos Alberto Casalnuovo , Ezequiel Ochoa de Eguileor, Horacio Rozas, María Panzitta. Hospital de Clínicas, University of Buenos Aires, and Private Practice (CCO-Centro de Cirugía de la Obesidad), Buenos Aires, Argentina. 17:06 49. Long-Term Experience with Lap-Band System. Marc Vertruyen. Europe St.Michel Clinic, Brussels, Belgium. 17:18 50. Lap-Band, Safe and Effective Procedure: 4 year Follow-Up. J.A. Lopez Corvala, F.Cordero Guzman, A.A.A. Ortiz Lagardere. Laparoscopic Group of Baja California, OBCT Control Center, Tijuana, Mexico.

356 Obesity Surgery,11, 2001 Crete Program 20:00 BusTransfer From Hotels To Chania. 20:30 Opening Ceremony – Chania Port of Old Town. 21:00 Welcome Reception, Cocktail and Buffet Dinner (Port of Old Town). 23:30 Bus Transfer from Chania to Hotels.

Thursday,September 6, 2001

GENERAL SESSION IPPOCRATES HALL

Session 1

Vertical Banded Gastroplasty

Moderators: Andrew C.Jamieson, Australia; Bernhard J. Husemann, Germany

08:30 51. Assessment of Different Bariatric Operations: Data up to 5 years from the Italian Registry (R.I.C.O). Mauro Toppino, Michaela Mineccia, Silvio Gorrino, *Roberta Siliquini, Francesco Morino, Registry Contributors. Department of Surgery, University of Turin, Department of Public Health, University of Turin, Italy. 08:45 52. Vertical Banded Gastroplasty: Results 10 Years after Surgery. Spiros Papavramidis, Isaak Kesisoglou, Dimosthenis Apostolidis , Orestis Gamvros. 3rd Surgical Department, AHEPA Hospital, Aristotelian University of Thessaloniki, Greece. 09:00 53. Long-term Results after VBG and Lap-Band. B.Husemann, T.H.Sonnenberg. Dominikus-Krankenhaus, Germany. 09:15 54. Laparoscopic Vertical Banded Gastroplasty vs Gastric Bypass – A Randomized Clinical Trial. Torsten Olbers, Hans Lönroth, Monika F-Olsén, Lars Lundell. Department of Upper GI Surgery , Sahlgrenska University Hospital, Gothenburg, Sweden. 09:30 55. A Randomized Prospective Study of Lap-Band vs VBG: an Interim Analysis on the Effects on Quality of Life and BMI. Francois van Dielen* , Ghislaine van Mastrigt**, Gemma Voss**, Jan Willem Greve*.Dept. of General Surgery* and Clinical Epidemiology and Medical Technology Assessment**, University Hospital of Maastricht, The Netherlands. 09:45 56. Laparoscopic Adjustable Silicone Gastric Banding (LASGB) vs Laparoscopic Vertical Banded Gastroplasty (LVBG): Intermediate Results of a Prospective, Comparative, Multicenter Trial. N.Basso, F.Favretti*, M.Morino**, U. Parini***, G.Silecchia, A.Restuccia , U. Elmore, M.Toppino**. Dipartimento di chirurgia “Paride Stefanini”, Policlinico “Umberto I ”Università “ La Sapienza”, Roma; Dipartimento Chirurgia Generale Osp S. Bortolo, Vicenza (ASL 6 Veneto), **Divisione Chirurgia, Università di Torino; ***U.O.Chirurgia Generale, Ospedale Regionale Valle d’Aosta, Italy.

10:00-10:30 COFFEE BREAK

10:30-11:00 Distinguished Lecture. Introduction: George S.M.Cowan Jr, U. S. A. The Physiology of Weight Loss and the Functioning of Bariatric Operations, Part II. Nicola Scopinaro, Italy

Obesity Surgery,11, 2001 357 Crete Program

Session 2

Surgical Treatment of Morbid Obesity and Super Obesity

Moderators: M.A.L. Fobi, U. S.A.;Rafael Capella, U. S.A.

11:00 57. 2010 Operations for Obesity in the Swedish SOS Study: Methods, Hospital Time and Complications. J. Hedenbro 1, I.Näslund 2, G. Ågren2, A.K.Lindroos 3, L.Sjöströ m 3.Depts. of Surgery at Lund 1 and Örebro2 University Hospitals and the SOS secretariat, Göteborg 3, Sweden. 11:15 58. Bariatric Surgery for the Super Obese: What is the Best Operation? Joseph F.Capella, Rafael F.Capella .Hackensack University Medical Center, Hackensack, NJ, U.S.A. 11:30 59. Malabsorptive Gastric Bypass in Patients with Super Obesity: Comparative Study of Roux Limb Length. Robert E.Brolin , Lisa B. Lamarca MS, RD, Ronald P.Cody, EdD. St.Peter’ s University Hospital and UMDNJ-RW Johnson Med Sch, New Brunswick, NJ, U.S.A. 11:45 60. Prospective Evaluation of the Fobi-Pouch Operation for Obesity: A Six-Year Follow-Up Report. M.A.L Fobi. Center For Surgical Treatment Of Obesity, Tri-City Regional Medical Center, Hawaiian Gardens, U.S.A.

12:00-12:30 POSTER VIEWING 12:30-14:00 LUNCH

Session 3

Special Lectures

Moderators: Mervyn Deitel,Canada; Latham Flanagan Jr,U. S.A.

14:00-14:30 From Paleosurgeon to Cybersurgeon Rafael Alvarez-Cordero, Mexico. 14:30-15:00 Current Status of Non-Adjustable Gastric Banding Martin Fried, Czech Republic. 15:00-15:30 Lessons Learned from 14 Years Experience with SAGB – Wireless Energy Transmission and Remote Control: a Better,Safer and Advanced Band. Peter Forsell, Sweden 15:30-16:00 Is Surgery the Most Cost-Effective Treatment for Morbid Obesity? David Kerrigan, UK.

16:00- 16:30 COFFEE BREAK

Session 4

Laparoscopic Gastric Banding

Moderators: Thomas P.Ricklin, Switzerland; Subhi Abu-Abid, Israel

16:30 61. Effects of Laparoscopic Gastric Banding on Body Composition, Metabolic Profile and

358 Obesity Surgery,11, 2001 Crete Program Nutritional Status in Morbid Obesity: 12 Months Follow-Up. V. Giusti1, M. Suter2, E. Zysset1, E.Hé raï ef 1, R.C. Gaillard 1, P .Burckhardt 1.Department of internal Medicine1 and Surgery 2, University Hospital – CHUV, Lausanne, Switzerland. 16:45 62. Flexible Gastric Band: Success of Interdisciplinary Team-Work? Thomas P.Ricklin 1 Natascha Potoczna 1, Grazyna Piec 1, Rudolf Steffen 2, F.Fritz.Horber 1,2 1Clinic Hirslanden Zürich, 2OBEX-Institutes, Zürich and Bern, Switzerland. 17:00 63. Laparoscopic Gastric Banding: One Surgeon, 400 Cases, Results and Complications. Paul Anderson .Oarlunga Hospital and Ashford Obesity Clinic, Adelaide, South Australia. 17:15 64. Laparoscopic Vertical Gastric Banding – Five Years Experience. Eliezer Avinoah , Leonid Landsberg, Solly Mizrahi. Surgery A, Soroka Medical Center, Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel. 17:30 65. Safety and Feasibility of LAGB Following Previous Failed SRVG. Subhi Abu-Abid , Ann Gorevich, Amir Szold. Surgery B, Bariatric Surgery and Advanced Laparo- scopic Surgery Unit, Tel Aviv, Suorasky Medical Center, Tel Aviv, Israel. 17:45 66. Laparoscopic Treatment of Complications after Vertical Banded Gastroplasty. Karl Miller, Emanuel Hell. Krankenhaus Hallein and Ludwig Boltzmann Institut fü r Gastroenterologie, Hallein, Salzburg, Austria.

Adjourn

Thursday,September 6, 2001

GENERAL SESSION (Concurrent) SAINT LUCAS HALL

Session 1 Malabsorptive Procedures

Moderators: Robert Brolin,U. S.A.;Roberto M.Tacchino, Italy

08:30 67. Contraceptive Therapy after Biliopancreatic Diversion in the Treatment of Morbid Obesity. R.Ceulemans, E.Gerrits, L.Hendrickx, E.Totté, R.Van Hee. Academic Surgical Centre Stuivenberg, Antwerp, Belgium. 08:42 68. Short-Term Comparison of “Long-Limb”Roux-en-Y Gastric Bypass versus Biliopancreatic Diversion with “Duodenal Switch”. T.Daskalakis, J. Nicastro, H. Mcmullen, S.Bianchi, M.Pagala, G.Coppa, J.N.Cunningham, J. Macura. Staten Island University Hospital, Staten Island, NY and Maimonides Medical Center, Brooklyn, NY, U.S. A. 08:54 69. Biliopancreatic Diversion (BPD) for Severe Obesity: Comparison at One Year of Scopinaro’s BPD and BPD with Transitory Gastroplasty Preserving Duodenal Bulb. F.Mittempergher, E.Di Betta, C. Casella, B.Salerni. Chair of General Surgery, University of Brescia, Italy. 09:06 70. Comparison of Micronutrien t Deficiencies after Roux-en-Y Gastric Bypass and Biliopancreatic Diversion with Roux-en-Y Gastric Bypass in Morbid Obesity. George Skroubis*, George Sakellaropoulos**, Nancy Mead*, George Nikiphoridis**, Fotis Kalfarentzos*.Nutrition Support and Morbid Obesity Clinic, Surgical Department* and Department of Medical Physics**, School of Medicine, University of Patras, Greece.

Obesity Surgery,11, 2001 359 Crete Program

09:18 71. Jejunoileal Bypass – Status 25 Years after the Operation. Villy Våge1, Jan Helge Solhaug 2, Asgaut Viste 3, Arnold Berstad 4.Department of Surgery , Fø rde 1, Deakon Hospital, Oslo 2, Department of Surgery 3 and Department of Medicine 4, Haukeland University Hospital, Bergen, Norway. 09:30 72. Improvement in Insulin Levels and Insulin Resistance after Biliopancreatic Diversion in Morbid Obesity With and Without Diabetes Type II. Maria Laura Cossu, Enrico Fais, Matteo Ruggiu, Claudio Sparta, Franca Cossu, Giuseppe Noya. Department of Emergency Surgery, University of Sassari, Italy. 09:42 73. Choice of Optimal Bariatric Procedure in the Treatment of Morbid Obesity. A.S. Lavryk, V-F.Sayenko, O.S. Tyvonchuk, O.P .Stetsenko, T.V.Masurak.Institute of Surgery and Transplantology, Kyiv, Ukraine.

10:00–10:30 COFFEE BREAK

10:30–12:30 Workshop: “Gastric Pacing”, sponsored by Transneuronix.

12:30–14:00 LUNCH

14:00-16:00 Workshop: “Innovation, Support and Long-term Experience: a Review of the LAP-BAND ® System, sponsored by BioEnterics.

16:00- 16:30 COFFEE BREAK

Session 2

Video

Moderators: Aniceto Baltasar, Spain; Ilan Charuzi, Israel

16:30 74. Early Experience with Laparoscopic Biliopancreatic Diversion (LBPD). Roberto M. Tacchino , Maurizio Foco, Gianni Greco, Marco Castagneto. Department of Surgery , Catholic University SH, Rome, Italy. 16:42 75. Laparoscopic Biliopancreatic Diversion – Technique and Initial Results. Dyker Paiva, Lucineia Bernardes, Livio Suretti. Surgical Department, Mater Dei Hospital, Belo Horizonte, Brazil. 16:54 76. Laparoscopic Scopinaro with Duodenal Switch and Associated Crural Repair and Cholecystectomy. George A.Fielding .Wesley Hospital and Royal Brisbane Hospital, Brisbane, Australia. 17:06 77. Laparoscopic Duodenal Switch. Technical Aspects. A.Baltasar, R.Bou, J.Miró , M.Bengochea, N.Pérez. Hospital “Virgen de los Lirios”, Alcoy, Alicante, Spain. 17:18 78. Swedish Adjustable Gastric Band (set pattern). Antelmo Sasso Fin .Hospital São Luiz, Brazil. 17:30 79. Laparoscopic Biliopancreatic Diversion for Morbid Obesity. Joaquin Resa , Jorge Solono. Hospital Royo, Villanova, Zaragoya, Spain. 17:42 80. The Pars Flaccida Technique in LASGB-Operation with New 11cm Lap-Band ®. Ralph Peterli, Peter Tondelli. Surgical Clinic, St.Claraspital, Basel, Switzerland.

Adjourn

360 Obesity Surgery,11, 2001 Crete Program

Friday,September 7, 2001

GENERAL SESSION IPPOCRATES HALL

Session 1

Gastric Banding

Moderators: Mitiku Belachew, Belgium; Patrice Lointier, France

8:30 81. Gastric Pouch Dilation following LAGB ® System Procedure: the Italian Experience. L.Angrisani , F.Furbetta, S.B. Doldi, N.Basso, M.Lucchese, M.Giacomelli, M.Zappa, E.Lattuada, L.Di Cosmo, A.Veneziani, G.U. Turicchia, F.Favretti, M.Alkilani, P.Forestieri, G.Lesti, F.Puglisi, M. Toppino, F.Campanile, F.D. Capizzi, C. D’Atri, L. Scipioni, C. Giardiello, N.Di Lorenzo, S.Lacitignola, M.Belvederesi, B. Marzano, G.Bernante, A.Luppa, V.Borrelli, M.Lorenzo. Italian Group for Lap- Band GILB, Naples, Italy. 8:45 82. Long-Term Results of Laparoscopic Adjustable Gastric Banding in three Major Centres in Belgium. M.Belachew* , C. Desaive**, P.Belva****Chr Huy, **Chu Liege, ***Chu Charleroi, Belgium. 9:00 83. Lap-Band, Prevention of Slippage: Series of 1410 Patients: Switching from the 9.5/10.0 Band to the New Generation 11.0 Band. Jean-Marie Zimmermann, Michel Blanc, Pierre Mashoyan, Érick Zimmermann, Jean-Marc Grimaldi. Clairval Private Hospital Center, Marseille, France. 9:15 84. Late Outcome of Adjustable Gastric Banding for Surgical Treatment of Morbid Obesity. Cornelius Doherty, James W.Maher , Debra Heitshusen, RN, BSN. Department of Surgery, School of Medicine, University of Iowa, Iowa City, Iowa, U.S.A. 9:30 85. Early Results with the Heliogast Band. Marc Vertruyen .Europe St.Michel Clinic, Brussels, Belgium. 9:45 86. Laparoscopic Experience with a New Adjustable Gastric Band. Patrice Lointier .Private Practice, Clermont-Ferrand, France.

10:00-10:30 COFFEE BREAK

10:30-11:00 Presidential Address: Introduction: Emanuel Hell Obesity Surgery – Pain, Privilege and Responsibility. Andrew C. Jamieson, Australia

Session 2

Gastric Pacing

Moderators: Henry Buchwald, U. S.A.;Ingmar Näslund, Sweden

11:00 87. Pacing the Stomach: Our Experience on Two Obese Patient Populations. V. Cigaina*, A. Saggioro*** Unit of Digestive Surgical Electrophysiology O. C. “Umberto I”Mestre-

Obesity Surgery,11, 2001 361 Crete Program Venezia, Italy**;Digestive Diseases & Clinical Nutrition Departments O.C.“ Umberto I”Hospital Mestre-Venezia, Italy. 11:15 88. Implantable Gastric Stimulation: Preliminary Results in France. Jerome Dargent .Polyclinique de Rillieux, Private Practice, France. 11:30 89. Successful Use of Endoscopic Ultrasound (EU) to Verify Lead Placement for the Implantable Gastric Stimulator (IGS™) Scott A.Shikora , Tamsin A.Knox, Laurence Bailen, Frederick J.Doherty, Christa M. Trigilio, PA-C. New England Medical Center, Boston, MA, U. S.A.. 11:45 90. Gastric Pacing versus Gastric Banding in Morbid Obesity - the Magdeburg Experience. S. Wolff, C Gerards *, H.Lippert, P.Malfertheiner*. Dept. Surgery, Dept. Gastroenterology, University of Magdeburg, Germany.

12:00-12:30 POSTER VIEWING 12:30-14:00 LUNCH

Session 3

Special Presentations

Moderators: George S. M.Cowan Jr, U. S.A.;David Kerrigan, U. K.

14:00-14:30 Lap-Band System ®:the Choice of the Patient. George A.Fielding, Australia;Roberto Rumbault, Mexico. 14:30-14:50 Progress in Bariatric Surgery, OBESITY SURGERY Journal and Report on IFSO. Mervyn Deitel, Canada. 14:50-15:00 IFSO Meeting in 2002, São Paulo. Arthur B. Garrido Jr, Brazil.

Session 4

Adjustable Gastric Banding

Moderators: Andreas Glättli, Switzerland; Carlos F.Escalante, Spain

15:00 91. Comparative Study Between Lap-Band and Swedish Adjustable Gastric Banding. J.M. Fabre, D.Nocca, M.C. Lemoine, C. Vacher, C. de Seguin, E.Renard, J.Domergue. Hôpital Saint Eloi, Montpellier,France. 15:15 92. Swedish Adjustable Gastric Band: Principles of an Optimal Band Adjustment . Hans Triaca-Bernasconi, Guido Stirnimann, Christian Klaiber. Hospital of Aarberg, Switzerland. 15:30 93. A Comparison of Complication Rates in 151 Cases of Lap-Banding and 174 Cases of the Swedish Adjustable Gastric Banding. James D.Ritchie .Keyhole Surgery Centre, Sydney, Australia. 15:45 94. Reduction of Obesity-Related Co-Morbidity after Laparoscopic Gastric Banding (SAGB ®). A. Glättli,1,3 G.Stirnemann 2, S. Schlatter 1, R. Stouthandel 1, H. Triaca2, Ch. Klaiber 2.Zieglerspital Bern1, Spital Aarberg 2, Salem-Spital Bern 3, Switzerland.

16:00- 16:30 COFFEE BREAK

362 Obesity Surgery,11, 2001 Crete Program

Session 5

Biliopancreatic Diversion

Moderators: Nicola Scopinaro, Italy;S. Ross Fox, U. S.A.

16:30 95. Biliopancreatic Diversion with Roux-en-Y Gastric Bypass (BPD with RYGBP) for the Super Obese: Preliminary Results. Nancy Mead, George Skroubis, Neoklis Kritikos, Klea Soulikia, Aggeliki Loukidi, Fotis Kalfarentzos. Nutrition Support and Morbid Obesity Clinic, Surgical Department, University Hospital of Patras, Greece. 16:45 96. Long-term Results of Biliopancreatic Diversion in Subjects with Prader-Willi Syndrome. Francesco Papadia, Giuseppe M.Marinari, Giovanni Camerini, Federica Murelli, Paola Marini, Cesare Stabilini, Flavia Carlini, Nicola Scopinaro. DICMI, Semeiotica Chirurgica R, University of Genoa School of Medicine, Genoa, Italy. 17:00 97. Biliopancreatic Diversion, Postoperative Management Challenges, Experience with 198 Cases Over 7 Years. James D.Ritchie .Keyhole Surgery Centre, Sydney, Australia. 17:15 98. Our Bariatric Surgery Experience with Bilio-intestinal Bypass. Santo Bressani Doldi , G.Micheletto, M.Perrini.Cattedra di Chirurgia Generale dell’Università degli Studi di Milano, Istituto Clinico Sant’ Ambrogio; Centro per la Farcomacoterapia delle Malattie Nutrizionali e Metaboliche “E.Genovese e R.Klinger”(Direttore Scientifico:Prof. S.B. Doldi), Milan, Italy. 17:30 99. Intestinal Obstruction after Malabsorpti ve Procedures: Still a Potentially Deadly Complication. Kenneth B. Jones Jr .Christus Schumpert Health System, Shreveport, LA, U.S.A. 17:45 100. Malabsorptive Surgery in the Therapy of Superobesity: Reasons to Choose Between the “DOC”B.P .D Technique and its Variants, Gastric Bypass and Intestinal Bypass. C.Vassallo, M.Andreoli, G.Berbiglia, A.Pessina, D. Savioni. Private Practice, “Morelli”Clinic, Pavia, Italy.

20:30 Bus Transfer to “Metoxi”Restaurant 21:00 Cretan Night 24:00 Bus Transfer to Hotels

Obesity Surgery,11, 2001 363 Crete Program Friday,September 7, 2001

GENERAL SESSION (Concurrent) SAINT LUCAS HALL

Session 1

Gastric Bypass

Moderators: Kenneth B.Jones Jr,U. S.A.;Emanuel Hell,Austria

08:30 101. Flexible Endoscopy in the Management of Patients Undergoing Roux-en-Y Gastric Bypass. Bruce Schirmer , Anna Miller, RN. University of Virginia Health Sciences Center, Charlottesville, VA, U.S.A. 08:42 102. Objective Assessment of the Effect of Laparoscopic Gastric Bypass on Esophageal pH and Motility in Morbidly Obese Patients with GERD. Emma J.Patterson, Yashodhan S.Khajanchee, Lee L.Swanstrom. Legacy Health System, Portland, Oregon, U.S.A. 08:54 103. Prophylactic Cholecystectomy with Gastric Bypass Operation - Incidence of Gallbladder Disease. Daniel Igwe Jr, Malgorzata Stanczyk, Basil Felahy , Hoil Lee, E.James , Nicole Fobi, MAL Fobi. Center for Surgical treatment of obesity, Hawaiian Gardens, CA, U.S.A 09:06 104. Initial Experience with Open and Laparoscopic Gastric Bypass in Naples. Luigi Angrisani , Vicenzo Borelli, Michele Maresca, Michele Lorenzo, Gaetano Cimmino, Monica Ciannella, Monica Giuffre, Annalicia Mozzillo.Unit of Endoscopy Surgery, “ S. Giovanni Bosco” Hospital Naples. 09:18 105. Leakage after Roux-en-Y Gastric Bypass. A.Westling, M.D.Sundbom, S.Gustavsson.University Hospital, Uppsala, Sweden. 09:30 106. A New Technique for Making a Fully Stapled Divided Gastric Bypass: 1-3 Year Results. J.Hedenbro, S. F.Frederiksen, M.Flemming. Department of Surgery at Lund University Hospital, Lund, Sweden. 09:42 107. Laparoscopic Gastric Bypass: Results in 76 Patients. Hans Lö nroth , T orsten Olbers, Lars Lundell. Department of Upper GI-Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.

10:00-10:30 COFFEE BREAK

10:30-12:30 Workshop: “Remote Control Gastric Banding”, sponsored by Obtech. 12:30-14:00 LUNCH 14:00-16:00 Workshop: “A New Era for Laparoscopic Antiobesity Procedures, with the Use of EndoGIA Universal® and Ligasure ® Laparoscopic Vessel Sealing System”, sponsored by Tyco.

16:00- 16:30 COFFEE BREAK

364 Obesity Surgery,11, 2001 Crete Program

Session 2 Video Session

Moderators: James A.Sapala, U. S.A.;Antonio Cascardo, Argentina

16:30 108. Micropouch Gastric Bypass. James A.Sapala , Michael H.Wood, Michael P.Schuhknecht, Thomas M.Flake Jr, M.Andrew Sapala. St.John Weight Loss Institute, St.John Detroit Riverview Hospital, Detroit, MI, U. S. A. 16:42 109. Laparoscopic Gastric Bypass Exactly Reproduces the Open Technique. I. Díez del Val , C. Martínez Blázquez , J.M.Vitores López , V.Sierra Esteban, J.Valencia Cortejoso J.D.Sardón Ramos. Hospital Txagorritxu, Vitoria-Gasteiz, Spain. 16:54 110. Big Guys – Lap Banding for Super Obesity. George A.Fielding. Wesley Hospital and Royal Brisbane Hospital, Brisbane, Australia. 17:06 111. Laparoscopic Gastric Bypass with Manual Anastomosis. Antonio Cascardo, Silvio Albarracín, Adrian Alvarez.IMETCO (Multidisciplinary Institute Specialized in the Treatment and the Surgery of Obesity), Buenos Aires, Argentina. 17:18 112. Implantable Stimulator (IGS TM) for Treatment of Severe Obesity: Initial Experience in Greece. J. Melissas, G. Shoretsanitis, J. Michalakis, H. Sonidas, G.Georgopoulou. Bariatric Unit, Dept. of Surgical Oncology, University Hospital, Heraklion, Crete, Greece. 17:30 113. The Use of a Nitinol U-CLIP (Coalescent Surgical Inc) for Advanced Laparoscopic Procedures Including Gastric Bypass. Marina S. Kurian, Valavanur Subramanian, Mitchell S. Roslin.Department of Surgery , Lenox Hill Hospital, New York, NY, U. S.A.. 17:42 114. Laparoscopic Long Vertical Gastric Stapling ±Sleeve Gastrectomy for the Treatment of Morbid Obesity. Simon P.L. Dexter , Michael J.McMahon, Nikos Georgopoulos. Leeds Institute for Minimally Invasive Therapy, The General Infirmary, Leeds, UK.

20:30 Bus Transfer to “Metoxi”Restaurant 21:00 Cretan Night 24:00 Bus Transfer to Hotels

Saturday,September 8, 2001

GENERAL SESSION IPPOCRATES HALL

Session 1

Various Surgical Methods for Treatment of Obesity

Moderators: Isao Kawamura, Japan; Khaled Gawdat, Egypt

09:00 115. Technical Strategy of Hals-Gastric Bypass for the Super/Super Obese Patient. Isao Kawamura 1, Kazuma Yamazaki 1, Masaaki Kodama 1, Okamichi Morikawa 1, Y ukimasa

Obesity Surgery,11, 2001 365 Crete Program

Miyazawa2, T akenori Ochiai 2.J.A.Marronier Medical Center, Shimotsuga General Hospital 1 Department of Surgery, Chiba University School of Medicine 2, Japan. 09:12 116. Gastroenteric Bypass: Modification of the Technique. Antonio Cascardo, Silvio Albarracín, Adrian Alvarez.IMETCO (Multidisciplinary Institute Specialized in the Treatment and the Surgery of Obesity), Buenos Aires, Argentina. 09:24 117. A Comparative Study Between Four Bariatric Procedures: Is there an Ideal Procedure yet? Khaled Gawdat. Ain Shams School of Medicine, Cairo, Egypt. 09:36 118. Combined Surgery for Morbidly Obese with Reflux Esophagitis. Alaa Abbass S. Moustafa , Essam Abd el Gelil.Ain Shams University and Ahmed Maher Teaching Hospital, Cairo, Egypt. 09:48 119. Electrogastrography in Morbidly Obese Patients. Francois van Dielen* , Freek Daams**, Bas de Cock*, Robert-Jan Brummer**, Jan Willem Greve*. Dept. of General Surgery* and Gastroenterology**, University Hospital Maastricht, The Netherlands.

Session 2

Gastric Banding

Moderators: Martin Fried, Czech Republic; Andriy Lavryk, Ukraine

10:00 120. Is the Laparoscopic Rebanding for Pouch Complications after Laparoscopic Gastric Banding the Right Choice?. M. Weber1, M.K.Müller 1, F. Horber2, L.Krähenbü hl, R.S. Hauser 3.1. University Hospital , Clinic for Visceral Surgery, Zürich; 2. Klinik Horslanden, Zürich; 3. Consultant for Nutrition, Zürich, Switzerland. 10:12 121. Lap-Band Erosion: Incidence and a Way of Treatment. Erik Niville. Ziekenhuis Oost Limburg, Genk, Belgium. 10:24 122. Laparoscopic Adjustable Gastric Banding: Personal Experience. Marcello Lucchese , Andrea Valeri, Giovanni Cantelli, Ingrid Paulin, Saverio Reddavide, Domenico Borrelli.Dept. of Gen. and Vasc.Surgery , Policlinico di Careggi, Florence, Italy. 10:36 123. Adjustable Silicone Gastric Banding for Revision of Failed Gastric Bariatric Procedures. Shlomo Kyzer , Aznat Raziel, Ofer Landau, Alexander Matz, Ilan Charuzi. Department of Surgery “B”, E.Wolfson Medical Center, Holon, Israel. 10:48 124. Quality of Life following Laparoscopic Gastric Banding for Obesity. Reyad Al-Ghnaniem* , Andrew Dettrick§, George A.Fielding§, Ameet G.Patel**.King’ s College Hospital, London, UK; §Wesley Medical Centre, Brisbane, Australia.

11:00-11:30 COFFEE BREAK

Session 3

Intragastric Balloon

Moderators: Jerome Dargent, France; Jean-Luis Allé, France

11:30 125. Intragastric Balloon Technique for the Treatment of Severe Obesity: Short-term and Mid-Term Follow-Up of the First 52 Patients in Argentina. Cormillot Alberto , LaRegina Rosana, Pozzoni Carlos, Diz Alejandro, Argonz Julio, Fuchs Analia.

366 Obesity Surgery,11, 2001 Crete Program Clínica de Nutrición y Salud, Buenos Aires, Argentina. 11:42 126. Bioenteric Intragastric Balloon (BIB):Retrospective Analysis. D.Raemdonck* , P.Belva*, P.Rotsaert*, J.C. Lefebvre*, M.Takkiedine*, P.Vaneukem*, A.Bailly **. Department of Digestive Surgery*, Department of Clinical Nutrition**, CHU Charleroi, Charleroi, Belgium. 11:54 127. Are Intragastric Balloons Useful in the Management of Obesity? A.E.E.Elewaut, A.Z. Groeninge. Campus Onze-Lieve-Vrouw, Department of Gastroenterology , Belgium. 12:06 128. The new Intragastric Balloon (BIB):a French experience of 23 cases, with Adjunction of a High-Protein Diet Jerome Dargent .Laurence Poulain, Dietitian. Private practice, Polyclinique de Rillieux.Rillieux-la- pape, Cedex, France. 12:18 129. Treatment of Morbid Obesity with Intragastric Balloon (BIB) in Association with Diet. Santo Bressani Doldi, G.Micheletto, M. Perrini, M.C. Librenti*, S. Rella*. Cattedra di Chirurgia Generale dell’Università degli Studi di Milano, Istituto Clinico Sant’ Ambrogio, Centro per la Farcomacoterapia delle Malattie Nutrizionali e Metaboliche “E.Genovese e R.Klinger”, *Unità di Malattie Metaboliche, Istituto Clinico San Siro, Milan, Italy.

Session 4

Novelties in Bariatric Surgery

Moderators: Anna Maria Wolf,Germany; Ahmed Zayed, Kuwait

12:30 130. Preliminary Report on Surgical Intervention on Patients with BMI>32 but <40 without Life- Threatening Comorbidities. MAL Fobi. Center For Surgical Treatment of Obesity , T ri-City Regional Medical Center, Hawaiian Gardens, CA, U.S.A. 12:42 131. Tissue Adhesive for Bariatric Surgery. Alan C. Roberts*, Steve Pollard**.*Academic Surgical Unit, University of Hull Medical School, England; **Department of Surgery, St James’s Hospital, Leeds, England. 12:54 132. Correlation Between Fat Distribution, Hyperlipidemia, Diabetes and Coronary Heart Disease In Morbidly Obese Patients. Anna Maria Wolf , Burkhard Kortner, Hans Werner Kuhlmann, Ulrike Beisiegel*. General Surgery, Evangelisches und Johanniter Klinikum Duisburg, Dinslaken, Oberhausen gGmbH, Germany. *Medical Clinic, University Hospital Hamburg-Eppendorf, Germany. 13:06 133. Four-Year Evaluation of Three Surgical Techniques. Rafael Alvarez-Cordero, V.E.Aragón, R.J.Montoya, A.O.Sandoval, D. A.Toledo. Hospital Angeles del Pedegral, México City, México. 13:18 134. From Open to Laparoscopic Gastric Bypass. I. Díez del Val , C. Martínez Blázquez, J.D. Sardón Ramos, J.M.Vitores López, V.Sierra Esteban, J.V alencia Cortejoso. Hospital Txagorritxu, Vitoria-Gasteiz, Spain.

Obesity Surgery,11, 2001 367 Crete Program Saturday,September 8, 2001

GENERAL SESSION (Concurrent) SAINT LUCAS HALL

Session 1

Adjustable Gastric Banding

Moderators: Rafael Alvarez-Cordero, Mexico; Mustafa Taskin, Turkey

09:00 135. Laparoscopic Gastric Banding for the Massively Obese. George A.Fielding. Wesley Hospital and Royal Brisbane Hospital, Brisbane, Australia. 09:12 136. How Can a New Technique for Laparoscopic Placement of the Adjustable Gastric Band (Lap-band) Prevent Slippage? D.Wagner, R.Weiner,* U. Winterberg, H.Bockhorn. Chirurgische Klinik Krankenhaus Nordwest Frankfurt am Main und Chirurgische Klinik Krankenhaus Sachsenhausen, Frankfurt am Main*, Germany. 09:24 137. Influence of Gastric Perforation, Simultaneous Cholecystectomy and Wound Infection on Late Postoperative Complications. Christine Stroh, Haralad Schramm , Ulrich Hohmann. Wald-Klinikum Gera gGmbH i.G.,Departement für Allgemeine Viscerale und Kinderchirurgie, Gera, Germany. 09:36 138. Is a Routine Gastrografin ® Swallow Following Laparoscopic Gastric Banding Mandatory? H. Nehoda, K. Hourmont, R.Mittermair, M. Lanthaler, T.Sauper, R.Peer*, F .Aigner, H.Weiss. Department of General Surgery/Department of Radiology*, University Hospital of Innsbruck, Austria. 09:48 139. Motility Disorders of the Esophagus following Adjustable Gastric Banding Operations. F.Schmoeller, G.Boehm*, K.Krichbaumer, M.Sengstbratl, R.Fuegger, F.Miess*.Department for Surgery, Department for Radiology*, Elisabethinen Hospital, Linz, Austria.

Session 2

Co-morbidities

Moderators: Yury I.Yashkov,Russia; Spiros Papavramides, Greece

10:00 140. Control and Regression of Type II Diabetes after Bariatric Surgery G.Vargas *, H. Cardoso*, M. Monteiro*, A.Sergio**, F .Pichel*, I. Pereira, M.J.Santos***, C. Cunha***, F.Bravo ***, Carvalho-Santos***, H.Ramos*. Department of Endocrinology, Diabetes and Metabolism*; Department of Surgery 2** and Department of Clinical Chemistry ***, San Antonio General Hospital, Porto, Portugal. 10:12 141. Behavior of Insulin Resistance and Leptin Levels after Bariatric Surgery. Bruno Geloneze, José Carlos Pareja, Enrico Repetto, Roberto Teixeira , Silka Geloneze, Marcos Tambascia, UNICAMP- State University of Campinas, Brazil. 10:24 142. Improvement of Obesity-Associated Co-Morbidity after Bariatric Surgery: Follow–up of 18 Patients During 24 Months. H. Cardoso, M.Monteiro, G.Vargas, A.Sergio, F.Pichel, I.A.Pereira, M.J.Santos, C. Cunha, F.Bravo, Carvalho-Santos, H.Ramos. Depts. of Endocrinology , Diabetes and Metabolism, Surgery 2 and

368 Obesity Surgery,11, 2001 Crete Program Clinical Chemistry, San Antonio General Hospital Porto, Portugal. 10:36 143. Reducing Risks in Bariatric Surgery: Is Sibutramine Useful? Enrico Repetto, Bruno Geloneze, José Carlos Pareja , Roberto Teixeira, Marcos Tambascia. UNI CAMP-State University of Campinas, SP, Brazil. 10:48 144. Insulin Resistance in the Severely Obese and Links with Metabolic Co-morbidities. Richard S. Stubbs , Kusal Wickremesekera.Wakefield Gastroenterology Centre, Wellington, New Zealand.

11:00-11:30 COFFEE BREAK

Session 3

Research and Surgical Treatment of Obesity

Moderators: Antonio Sergio Bastos Silva, Portugal; Richard S.Stubbs, New Zealand

11:30 145. Effect of Excessive Weight Loss on Immune-Regulatory Mechanisms in Morbidly Obese Patients. H.Weiss, H.Schwelberger, J.Klocker, B.Labeck, H.Nehoda, F.Aigner, G.Weiss.Departments of General Surgery and Internal Medicine, University Hospital Innsbruck, Austria. 11:42 146. Normal Enoxoparin Doses Give too Low Plasma Values in Morbid Obesity. S. G.Frederiksen, L. Norgren, J.L.Hedenbro. Department of Surgery, Lund University Hospital, Lund, Sweden. 11:54 147. Safety of Bilateral Vagus Nerve Stimulation for Obesity. M. S. Roslin, M.Kurian, M.Genovesi, F.Moody.Lenox Hill Hospital, New York, NY; University of Texas at Houston, Houston, TX, U.S.A. 12:06 148. Surgical Treatment of Obesity by Gastric Banding. Jean-Jacques Sala. Clinique Clement Drevon, Dijon, France. 12:18 149. Heliogast vs Lap-Band Gastroplasty. Jacques Himpens, Guido Leman. St.Blasius Hospital, Dendermonde, Belgium.

Session 4

Vertical Banded Gastroplasty

Moderators: George Schoretsanitis, Greece; Shrihari Dhorepatil, India

12:30 150. Weight Loss Results of Vertical Banded Gastroplasty in Superobese Patients. Yury I. Yashkov , Tatiana A.Oppel, Oleg G.Skipenko. Russian Research Center of Surgery, Moscow, Russia. 12:42 151. Vertical Banded Gastroplasty: A 12-year Experience. A.l.Papakonstantinou, P.Alfaras, V .Komessidou, J.Terzis, P .Moustafelos, S. Gourgiotis, T.Anastasiou, E.Niakas, E. Mamplekou, E.Hadjiyannakis. 1st Surgical Department and Transplantation Unit of the Gen. Hospital of Athens “EVANGELISMOS”, Athens, Greece. 12:54 152. Vertical Banded Gastroplasty with Silicone Ring: First Experience in Romania for the Surgical Treatment of Severe Obesity. Romeo Florin Galea , A.Ciule, D.Mircioiu, Dana Pintea, Florinela Galea. The Second Surgical Clinic,

Obesity Surgery,11, 2001 369 Crete Program UMF, Cluj-Napoca, Romania. 13:06 153. Modified VBG for Morbid Obesity - An Early Indian Experience. Shrihari Dhorepatil .Jahangir Hospital Center, Pune, India. 13:18 154. Ten Years of Experience of VBG in Open Surgery. Stefano Cariani, D. Nottola, G.Vittimberga, S.Grani, A.Lucchi, F.Mancini, E.Amenta. Università di Bologna, Dipartimento di Scienze Chierurgiche ed Anestesiologiche, Centro Studi diterapia Chirurgica dell’Obesità Patologica, Bologna, Italy.

Adjourn

POSTERS

P1. Optimal Timing of Incisional Hernia Repair and Laparoscopic Gastric Banding. H.Bonatti, W.Kirchmayr, H.Nehoda, F.Aigner, P.Kronberger, H.Weiss.Dept of General Surgery, University Hospital, Innsbruck, Austria. P2. Regression of Hyperandrogenism in Obese Females Submitted to Bariatric Surgery. M.Monteiro, H.Cardoso, G.Vargas, F.Pichel, I. A.Pereira, A.Sergio, M.J.Santos, C. Cunha, F.Bravo, Carvalho-Santos, H.Ramos. Depts. of Endocrinology , Diabetes and Metabolism, Surgery 2 and Clinical Chemistry.San Antonio General Hospital, Porto, Portugal. P3. Effect of Massive Weight Loss in Glucose Tolerance and Ghrelin, a Novel Gut Hormone. Victor Pilla, José Carlos Pareja, Enrico Repetto, Bruno Geloneze, Silka Geloneze, Marcos Tambascia. UNI CAMP, State University of Campinas, SP, Brazil. P4. Relationship Between Ghrelin and Leptin in Obese Subjects. José Carlos Pareja, Victor Pilla, Bruno Geloneze, Enrico Repetto, Silka Geloneze, Marcos Tambascia. UNI CAMP, State University of Campinas, SP, Brazil. P5. Type-2 Diabetes, Glucose Control and Insulin Resistance following Massive Weight Loss. Bruno Geloneze, José Carlos Pareja, Enrico Repetto, Silka Geloneze, Roberto Teixeira , Marcos Tambascia. UNICAMP, State University of Campinas, SP, Brazil. P6. Inflammatory Markers, Insulin Resistance and Weight Loss following Bariatric Surgery. Bruno Geloneze, José Carlos Pareja, Enrico Repetto, Roberto Teixeira , Silka Geloneze, Marcos Tambascia. UNICAMP, State University of Campinas, SP, Brazil. P7. Insulin Resistance and Uricemia in Severely Obese Subjects Following Bariatric Surgery. Bruno Geloneze, José Carlos Pareja, Enrico Repetto, Silka Geloneze, Marcos T ambascia. UNICAMP, State University of Campinas, SP, Brazil. P8. Integrated Surgical Approach to Obesity. George A.Fielding. Wesley Hospital and Royal Brisbane Hospital, Brisbane, Australia. P9. Laparoscopic Adjustable Gastric Banding in Super Morbid Obese: an Egyptian Experience. Hany Aly Nowara .Assistant Professor Of Surgery, Cairo University, Hospital and Mokattam Surgery Center, Cairo, Egypt. P10. Bariatric Surgery for Children and Adolescents: What are the Indications? Khaled Gawdat , Ashraf Kabesh. Ain Shams School of Medicine, Cairo, Egypt. P11. The Evaluation of Etiology,Risk Ractors, Complications and Benefit, Using the Data Base “Obesity 2.0”for Laparoscopic Bariatric Surgery. D. Wagner, R.Weiner, U. Winterberg, H.Bockhorn. Department of Surgery, KH Nordwest, Frankfurt a.M, Germany. P12. Lap-Band - persisting Good Result with Slipped Band by Modified Technique. George A.Fielding. Wesley Hospital and Royal Brisbane Hospital, Brisbane, Australia. P13. The Effects of Long Limb Gastric Bypass on Monocyte Dysfunction in Morbid Obesity. L.D.G.Angus, D. R.Cottam, D.Fahmy, G.W.Shaftan, P.A.Schaefer. Nassau University Medical Center,

370 Obesity Surgery,11, 2001 Crete Program Department of Surgery, East Meadow, New York, U.S.A. P14. Abnormal Videofluoroscopic Findings in Patients After Laparoscopic Gastric Banding. G. Boehm1, F .Schmoeller 2, K. Kriechbaumer 2, F. Miess1, R. Függer2. 1Department of Radiology , 2Department of Surgery, Elisabethinen Hospital Linz, Austria. P15. Esophago-Gastric Laparoscopic Placement of Lap-Band for Morbid Obesity: Considerations After the First 80 Cases. Sergio Boschi, L.Fogli, A.Cuppini*, M.Brulatti, P.Patrizi, V.Papa, M.Di Domenico, F.D.Capizzi.General Surgery and *Internal Medicine, Bellaria Hospital, Bologna, Italy. P16. Apolipoprotein E and CIII in Patients with Obesity-Related Phenotype BMI after Bariatric Surgery. J.C. Cagigas (*), Alfredo Ingelmo (*), R.Hernandez-Estefania,, D. Gonzalez-Lamuño, M.Garcia-Ribes, S. Revuelta (*), C. Escalante. Nutrition and Cardiovascular Risk Unit, University of Cantabria, General Surgery. Hospital Universitary Valdecilla, Hospital Sierrallana (*), Spain. P17. Obesity Surgery Pitfalls and Morbidity at 10-year Follow-Up with Vertical Banded Gastroplasty. J.C. Cagigas(*), Alfredo Ingelmo (*), R.Hernandez-Estefanía, F.Olmedo, S. Revuelta (*), E.Martino, C. F. Escalante. Hospital Valdecilla, Hospital Sierrallana(*), University of Cantabria. Spain. P18. Small Bowel Obstruction following Long Limb Roux-en-Y Gastric Bypass for Morbid Obesity: Presentation of 3 Cases. T.Daskalakis, J. Nicastro, H. Mcmullen, G.Coppa, J.N. Cunningham, J.Macura. Maimonides Medical Center, Brooklyn, NY and Staten Island University Hospital, Staten Island, NY, U.S.A. P19. The Use of Endostaplers in the Reconversion of a Failed Vertical Banded Gastroplasty to Biliopancreatic Diversion (Scopinaro). C. F.Escalante, A.Domínguez-Diez , A.Ingelmo, F.Olmedo, M.G.Fleitas.Institute of Digestive Diseases. Hospital U, “Marqués de Valdecilla”, Santander, Spain. P20. Quality of Life after Roux-en-Y Gastric Bypass. Joel Faintuch, Priscilla L.R.C. Machado, Monica A.Rudner, Arthur B. Garrido Jr , Luiz V.Berti, Marlene M. Silva, J.J.Gama-Rodrigues. Obesity Surgery Group, Hospital das Clinicas, Sao Paulo, SP, Brazil. P21. Response of Comorbidities to Roux-en-Y Gastric Bypass. Joel Faintuch, Monica A.Rudner, Priscilla L. R.C. Machado, Arthur B.Garrido Jr , Marcelo R.Oliveira, J.J.Gama-Rodrigues. Obesity Surgery Group, Hospital das Clínicas, Sao Paulo, SP, Brazil. P22. New Positioning of the Port System. Francesco Furbetta, G.Gambinotti. Ospedale di Pescia, Pescia, PT, Italy. P23. Minor Late Complication of Roux-en-Y Gastric Bypass. Sergio Z.Gil, Monica A.Rudner, Priscilla L.R.C. Machado, Joel Faintuch, Arthur B. Garrido Jr , J.J.Gama- Rodrigues. Obesity Surgery Group, Hospital das Clinicas, Sao Paulo, SP, Brazil. P24. Lowering the Complication Rate in LAP-BAND Procedures by Cooperation and Experience. Pavol Holéczy 1, Vladimí r Medveck 2, Holéczyová Albeta 1, Linhartová Nadeda 1. 1Surgical Department, Railway Hospital, Bratislava, Slovakia; 2Surgical Department, VS Hospital, Koice, Slovakia. P25. Prophylaxis of Thromboembolism in Bariatric Surgery. A.S. Lavryk, V.F.Sayenko, O.P .Stetsenko, O.S. Tywonchuk, V.J.Smorzhevsky, O.F .Bubalo. Institute of Surgery and Transplantology, Kyiv, Ukraine. P26. Body Composition Studies in Obese Children. Renata B. A.Leme, Marilisa S.Froes, Eduardo Meirelles, Ari L.Cardoso, Andrea Nascimento, Cristiane A. R.Charles, Arthur B. Garrido Jr, Joel Faintuch. Obesity Group, Children’s Institute and Hospital das Clinicas, Sao Paulo, SP, Brazil. P27. Does Reduction in Gastric Acid Secretion Increase the Daily Energy Expenditure? J. Melissas, E.Kampitakis, G. Schoretsanitis, E. Kouroumalis. Bariatric Unit, Dept. Surgical Oncology. University Hospital, Heraklion, Crete, Greece. P28. Gastro-Esophageal Reflux Disease in Obese Patients: Modifications Induced by Bariatric Surgery. Joaquin Ortega , Carlos Sala, Maria Escudero, Francisco Mora, Adolfo Benages, Vicente Sanchiz, Jose

Obesity Surgery,11, 2001 371 Crete Program Martinez-Valls, Salvador Lledo. Morbid Obesity and Endocrine Surgery Unit, Clinic Hospital and University of Valencia, Valencia, Spain. P29. Anastomotic Complications after Roux-en-Y Gastric By-pass for Morbid Obesity: A Safe Procedure. Joaquin Ortega , Carlos Sala, Jose Martinez-Valls, Salvador Lledo. Morbid Obesity and Endocrine Surgery Unit, Clinic Hospital and University of Valencia, Valencia, Spain. P30. Psychosocial Outcome of LASGB Operations in Adolescents. T.Pachinger, F.Schmoeller*. Private practice for clinical psychology , Elisabethinen Hospital Linz, Department of Surgery*,Austria. P31. Impact of Minimally Invasive Surgical Fellowship on Early Outcomes in Laparoscopic Bariatric Surgery Christine J. Ren, MD* , Marina Kurian, MD†, Mitchell Roslin, MD †, Emma Patterson, MD ‡.NYU School of Medicine, New York, NY*;Lenox Hill Hospital, New York, NY †;Legacy Health Systems, Portland OR ‡, U.S.A. P32. Use of BAROS Score System in Patients Operated on for Mobid Obesity: Results of our series. Carlos Sala , Joaquin Ortega, Fernando López, Stephanie García, Jose Martinez-Valls, Salvador Lledo. Morbid Obesity and Endocrine Surgery Unit, Clinic Hospital and University of Valencia, Valencia, Spain. P33. The Learning Curve in Bariatric Surgery: Implications in Morbidity and Costs. Carlos Sala , Joaquin Ortega, Jose Martinez-Valls, Salvador Lledo. Morbid Obesity and Endocrine Surgery Unit, Clinic Hospital and University of Valencia, Valencia, Spain. P34. Duodeno-Gastric Bile Reflux after Roux-en-Y Gastric Bypass. Magnus Sundbom , Sven Gustavsson.University Hospital, Uppsala, Sweden. P35. Bariatric Analysis and Reporting Outcome System following Laparoscopic Adjustable Gastric Banding in Finland. Mikael Victorzon, Pekka Tolonen. Department of Surgery, Vasa Central Hospital, Vasa, Finland. P36. Remifentanil Anesthesia can Reduce the Consumption Perioperative Intravenous Morphine in Biliopancreatic Surgery in Morbid Obesity. M.A.Villanueva, F.J.Barredo, A.Muñecas, S.G.Santos, A.Dominguez, C. F.Escalante. S Anestesiología y Reanimación Hosp Univ Marqués de Valdecilla, Santander, Cantabria, Spain. P37. Comparison of Respiratory Function Tests after T wo Different Anesthetic Techniques following Laparoscopic Morbid Obesity Surgery. Ziya Salihoglu*, Kagan Zengin**, Sener Demiroluk, Oktay Demirkiran*, Yildiz Kose*, Mustafa Taskin **. University of Istanbul, Medical Faculty of Cerrahpasa, Department of Anesthesiology* and General Surgery**, Istanbul, Turkey. P38. Conversion of Failed Vertical Banded Gastroplasty (VBG) to Open Adjustable Silicone Gastric Banding (ASGB). Mustafa Taskin *, Kagan Zengin*, Ethem Unal*, Ziya Salihoglu**. University of Istanbul, Medical Faculty of Cerrahpasa, Department of General Surgery * and Anesthesiology **, Istanbul, Turkey. P39. Band Erosions following Adjustable Silicone Gastric Banding (ASGB) for Morbid Obesity. Mustafa Taskin *, Kagan Zengin*, Ethem Unal*, Ziya Salihoglu**. University of Istanbul, Medical Faculty of Cerrahpasa, Department of General Surgery* and Anesthesiology**, Istanbul, Turkey. P40. Effect of Position Changes and Pneumoperitoneum on Respiratory Mechanics in Laparoscopic Morbid Obesity Surgery. Ziya Salihoglu*, Kagan Zengin**, Sener Demiroluk*, Serpil Cakmakkaya*, Yildiz Kose*, Mustafa Taskin ** University of Istanbul, Medical Faculty of Cerrahpasa, Department of Anesthesiology* and General Surgery**, Istanbul, Turkey. P41. Learning Curve of the Surgical Treatment of Morbid Obesity. A. Bozbora*, Y.Erbil *, S. Ozarmagan*, U. Barbaros*, N. Ozbey**, Y.Orhan**. *Department Of General Surgery, Istanbul Medical Faculty, Istanbul **Department of Internal Medicine, Istanbul Medical Faculty, Istanbul, Turkey. P42. Reoperations after Laparoscopic Adjustable Silicone Gastric Banding (Lap-Band ®).

372 Obesity Surgery,11, 2001 Crete Program U. Elmore, A.Restuccia, N. Perrotta, D .Polito*, E. Bianchi**, N. Lo Martire**, G. Silecchia, N. Basso. Dipartimento di chirurgia “Paride Stefanini”- Policlinico “Umberto I”Università “ La Sapienza”Roma” , *ASL Roma G, **ASL Frosinone Presidio Sora, Italy. P43. Bioenterics Intragastric Balloon; A Non-Aggressive Solution for the Treatment of Obesity? J.Herve; C. H.Wahlen; B.Bastens; B. Dallemagne; C. Jehaes; J.L. Jourdan; S. Markiewicz;J. Weerts.Les Cliniques Saint Joseph, Liege, Belgium. P44. Short-term Body Composition Changes Following Laparoscopic Adjustable Silicone Gastric Banding. A.Diez-Caballero, J.Gó mez-Abrosi, I. Monreal, J.Salvador, J.A. Cienfuegos, G.Frühbeck. Depts. of Surgery, Endocrinology and Biochemistry, Clí nica Universitaria de Navarra, Metabolic Research Laboratory, University of Navarra, Pamplona, Spain. P45. Laparoscopic Gastric Bypass for Morbid Obesity: First Experience with 15 Cases. M. Weber1, M.K.Müller 1, F. Horber2, L.Krähenbü hl, R. S. Hauser3. 1University Hospital Zürich, Clinic for Visceral Surgery, Zürich; 2Klinik Hirslanden; 3Consultant for Nutrition, Zürich, Switzerland. P46. Esophageal Dilatation following Laparoscopic Adjustable Silicone Gastric Banding. Dorothy R.Ferraro, MS, CS, ANP, Richard B. Rubenstein, Stuart Katz.Private Practice, Caremax Wellness and Weight Management Center, E.Patchogue, NY, U.S.A. P47. Laparoscopic Gastric Banding: The Long Island Experience. Dorothy R.Ferraro, MS, CS, ANP, Richard B. Rubenstein. Private Practice, Caremax Wellness and Weight Management Center, E.Patchogue, NY, U.S.A. P48. Dissociation of Plasma Leptin Concentrations with Insulin and Body Fat 24 hours after Laparoscopic Adjustable Gastric Banding. G.Frühbeck, A. Diez-Caballero, J.Gó mez-Abrosi, I. Monreal, J.Salvador, J.A. Cienfuegos. Depts. of Endocrinology, Surgery and Biochemistry, Clí nica Universitaria de Navarra, Metabolic Research Laboratory, University of Navarra, Pamplona, Spain. P49. Unilateral Lower Extremity Compartment Syndrome following a Laparoscopic Roux-en-Y Gastric Bypass: a Case Report. Piotr J. Gorecki;Daniel Cottam; L.D.George Angus; Ralph Ger; Gerald W Shaftan. Nassau University Medical Center, East Meadow, NY, U.S.A. P50. Management and Therapy of Postoperative Complications after Gastric Banding for Morbid Obesity. U. Winterberg, D.Wagner, H.Bockhorn. Chirurgische Klinik Krankenhaus Nordwest, Frankfurt am Main, Germany. P51. Laparoscopic Roux-en-Y Gastric Bypass with Silastic Ring (Capella’s Procedure) in the Treatment of Morbid Obesity: Early Results and Comparison to Technique without Silastic Ring. Thomas Szego, Arthur B. Garrido Jr, Mitsunori Matsuda, Carlos Jose Lazzarini Mendes, Marcelo Roque de Oliveira, Alexandre Elias, Luiz Vicente Berti.Private Practice, Albert Einstein and Beneficencia Portuguesa Hospital, Sao Paulo, Brazil. P52. Management of Biliopancreatic Diversion Complications. Santo Bressani Doldi, G.Micheletto, M. Perrini, E. Mozzi.Cattedra di Chirurgia Generale dell’Universita degli Studi di Milano, Istituto Clinico Sant’Ambrogio, Centro per la Farmacoterapia delle Malattie Nutrizionali e Metaboliche “E.Genovese e R.Klinger”, Milan, Italy. P53. Preliminary Study of a Single Institution’s Experience with 1,410 Cases of Adjustable Gastric Banding Performed from July 1995 to April 2001 (5-year Retrospective). Jean-Marie Zimmermann, Michel Blanc, Pierre Mashoyan, Erick Zimmermann, Jean-Marc Grimaldi. Clairval Private Hospital, Marseille, France. P54. Bariatric Surgery Complications with Adjustable Laparoscopic Gastric Band System (Lap-Band): Prevention and Treatment. Carlos Alberto Casalnuovo, Ezequiel Ochoa de Eguileor, Gustave Parrilla, Eduardo Liljesthrom.Hospital de

Obesity Surgery,11, 2001 373 Crete Program Clinicas, University of Buenos Aires, and Private Practice (CCO-Centro de Cirugia de la Obesidad), Buenos Aires, Argentina. P55. Changed Eating Behavior Produced by Chronic Bilateral Vagus Nerve Stimulation. M.S. Roslin, R. Reddy*, S.M.Parnis**, B. T.Barrett**.Lenox Hill Hospital, New York, NY , *Maimonides Medical Center, Brooklyn, NY, **Cyberonics, Inc, Houston, TX, U. S. A.. P56. Comparison of Different Techniques of Laparoscopic Placement of Adjustable Gastric Bands. R.Weiner, D.Wagner, R.Blanco-Engert. MIC-Zentrum Frankfurt-Sachsenhausen, Frankfurt a.M., Germany. P57. Minimally Invasive Reinterventions to Treat Complications after Bariatric Surgery. F.Aigner, H.Weiss, H.Nehoda, H.Bonatti. Univ.Hospital of Surgery, Dep. of Gen. Surg., Innsbruck, Austria. P58. Incidence of Smoking and Weight Loss in our Bariatric Population. Joseph F.Capella, Rafael F.Capella. Hackensack University Medical Center, Hackensack, NJ, U.S.A. P59. Solid State Barium Meal in Lap-Bands Inserted with Pars Flaccida Technique. Marina S. Kurian, Mitchell S. Roslin.Department of Surgery, Lenox Hill Hospital, New York, NY, U.S.A P60. The Influence of Gastric Banding on Plasma-Aminoxidase (PAO) - a Possible Prognostic Factor in Obesity-Associated Morbidity. J.Klocker, B. Labeck, H.Nehoda, F.Aigner, A.Klingler, C. Ebenbichler, B. Föger, M. Lechleitner, H. Schwelberger, H.Weiss.Departments of General Surgery and Internal Medicine, University Hospital Innsbruck, Austria. P61. Our Changing Approach to the Prophylaxis of Venous Thromboembolism in Bariatric Surgery. Maria Laura Cossu, Enrico Fais, Matteo Ruggiu, Claudio Sparta’, Franca Cossu, Giuseppe Noya. Department of Emergency Surgery, University of Sassari, Italy. P62. Hemodynamic and Cardiac Functional Improvements after SurgicalTreatment of Severe Obesity. F.Mittempergher, D.Moneghini, B.Salerni, S.Nodari*, A.Madureri*, L.Dei Cas*.Chair of General Surgery and *Chair of Cardiology, University of Brescia, Italy. P63. Laparoscopic Gastric Banding in the Elderly. H.Nehoda, K.Hourmont, T.Sauper, R.Mittermair, M.Lanthaler, F.Aigner, H.Weiss.Department of General Surgery, University Hospital of Innsbruck, Austria. P64. Routine Cholecystectomy Concomitant with Bariatric Surgery.Is it Needed? Spiros Papavramidis, Konstantinos Sapalidis, Nikolaos Deligiannidis, Ilias Papavasiliou, Orestis Gamvros. 3rd Surg. Dept. AHEPA Hosp. Aristotelian University of Thessaloniki, Greece. P65. Improvement in Metabolic Co-Morbidities following Weight Loss from Gastric Bypass Surgery. Richard S. Stubbs. Wakefield Gastroenterology Centre, Wellington, New Zealand. P66. Normal Body Weight: Is there a Realistic Chance after Bariatric Surgery? B. Husemann, Th. Sonnenberg. Dominikus-Krankenhaus, Dusseldorf, Germany. P67. Patient Characteristics Influencing Weight loss following LASGB-Operation. Ralph Peterli, Yael Anner, Peter Tondelli. Surgical Clinic, St.Claraspital, Basel, Switzerland. P68. Postoperative Thromboembolic Complications after Obesity Surgery. A.Westling, S. Gustavsson Assoc Prof.Department of Surgery, University Hospital Uppsala, Sweden. P69. Laparoscopic Biliopancreatic Diversion without Gastrectomy. Resa Joaquin. Hospital Royo Villanova, Zaragosa, Spain. P70. Quality of Life is Improving after Lap-Band Gastric Banding for Morbid Obesity. Beda Saida, Jean-Marc Chevallier , Frank Zinzindohoue, Richard douard, Jean-Louis Berta, Jean-jacques Altman, Paul-Henri Cugnenc. Departments of Surgery and Nutrition.Hô pital Européen Georges Pompidou, Paris, France. P71. Our Bariatric Surgery Experience with Adjustable Gastric Banding. S. B. Doldi, G.Micheletto, M.Perrini, E.Lattuada, M.A.Zappa, M.Fioravanti. Cattedra di Chirurgia Generale dell’Università degli Studi di Milano - Istituto Clinico Sant’Ambrogio, Centro per la Farcomacoterapia delle Malattie Nutrizionali e Metaboliche E.Genovese R.Klinger. Milan, Italy.

374 Obesity Surgery,11, 2001 Obesity Surgery, 11, 375-446 Allied Health Program

1.OBESITY SURGERY: UTILITY OF PSYCHOLOGICAL regarding preventative and treatment measures of osteoporo- AREA IN MULTIDISCIPLINARY TEAM AND FUTURE CHAL- sis. LENGES. The body lessons include how to visually educate the layper- Susana Bayardo, Silvio Albarrací n, Antonio Cascardo, Ana son to be able to understand the anatomy and how their surgery Cappelletti, Hernán Franco, Adrián Alvarez. IMETCO (Instituto will work for them. There will also be a discussion along with Multidisciplinario Especializado en el Tratamiento y Cirugía de educational material regarding what it means to have various la Obesidad) medical problems related to obesity, such as hypertension, dia- Background:Scientific research have proved remarkable betes, sleep apnea as well as what exercise can do for the body. achievements in reducing and keeping weight losing in operated Discussion that involves the “brain”is inclusive of the neces- patients with adjustable gastric banding, as well as their sity of having support groups as well as utilizing the services of improvements in quality of life.Control and follow up allows to psychologists, psychiatrists and therapists.The focus will be on observe the success of procedure related to the grade of com- the importance of psychological follow-up that should be made pliance to treatment. available to the individuals who have had weight loss surgery. Psychologic evaluation allows to know motivational aspects, personality features, psichopatological antecedents, pre and 3.THE “ INFO G”GROUP: A SUPPORT TEAM FOR THE post-surgery fears, psichosoc ial support and continence. OBESE PATIENT. Informed consentiment shows that the patient knows and Christian A.G. Thyse RN. Centre Hospitalier Régional de Huy, accepts to follow requirements.However, difficulties with com- Huy, Belgium pliance are frequently observed along the process.We are inter- At the begining of gastroplasty in our hospital, it was very diffi- ested in studying difficulties related to compliance, as it may cult to take care of the obese patient because of their psycho- frustrate initial expectations of patients when asking and accept- logical profile.T o help the staff and the patient, we have decided ing surgery. to have a meeting with the surgery staff and the allied health Methods:Self filled questionnaires were used as well as psy- staff.The proposed solution was the « INFO G» group chological pre and post surgery interviews in 100 patients who (Information and gastroplasty). This group is composed by a underwent adjustable gastric banding surgery at IMETCO Dietician, a Psychologist and a Nurse.After the first contact with (Instituto Interdisciplinario Especializado en el T ratamiento y the surgeon, the patient have to have an appointement with the Cirugía de la Obesidad) during the period 8/98 - 2000, with at group. least, one year post-surgery follow up. During a discussion with the patient, the psychologist and the Results of evaluation were checked with weith losing, atten- dietician try to describe his psychological and eating profile.The dance to medical interviews, and re-operations due to band dis- nurse is present to answer question about the nursing and the placement. care.Secondly , the patient come back with a repport of the the Results:Information from research, allows us to inform staff group, so that, the surgeon has a complete history of his patient about patient characteristics, which may interfere in adaptatin and can propose (or not) a surgical solution.If necessary, it is and compliance pre and post surgery.Results were concordant proposed to the patient to be followed by a psychological team to international statistics, in relation to percentages of weigh los- or a dietician before of after surgery.The role of the group is to ing.In patiens which results were not the expected because of give all the information needed by the patient about his future lack or poor compliance to the treatment, we have identified psi- way of live and his future eating attitude.It is also easyer to pre- chosocial factors which took part. vent and detect the failure risk. Conclusion:Nowadays, psychology gives multidisciplinary Conclusion:We have began this multidisciplinary approch 15 teams major instruments for treatment.Challenge consists on years ago and today we are sure that it can help the patient but improving some of them, regarding validity and reliability in also all the team for the obese patient management. detecting predicting factors, which are useful to get compliance related to surgery itself and post surgery treatment, as well as 4.PRELIMINARY SURVEY OF SEXUAL ORIENTATION to define characteristics for the kind of surgery which does not AFTER WEIGHT LOSS SURGERY IN HOMOSEXUAL depend on a conduct change. FEMALES. Delphine Nuglozeh-Buck, RN, Barbara Metcalf, RN, William 2.CONTINUING EDUCATION, OUR RESPONSIBILITY TO Harman, Ph.D., Gregg H.Jossart, MD, Robert A.Rabkin, MD TEACH LESSONS OF THE BODY,BONES AND BRAINS. Pacific Laparoscopy, San Francisco, CA, USA Jacquelyn K. Smiertka, RN. Bloomfield Bariatrics-Private Background: A subset of morbidly obese female patients who Practice, Michigan, USA were self-identified as homosexual before weight loss surgery Our patients come to us for help.Obesity surgery, known to was obtained from a large surgical bariatric practice. be the most viable treatment for this deadly disease, appears to Methods:In conjunction with routine post-operative follow-up be the only answer for millions of individuals all over the world. after surgery for mobid obesity, changes in sexual orientation Our most important responsibility following the preoperative were recorded.These changes were self-reported. educational process and safe surgery is the process of continu- Results:Changes in patients’sexual orientation occurred in a ing education. This paper will cover topics that will focus on significant minority of bariatric surgical patients. some of the lessons we can teach regarding the bones, the Conclusion:Transition to heterosexual orientation does occur body and the brains. after bariatric surgery.Future research may be helpful in guid- For those who do malabsorption procedures, materials will ing patients through often difficult periods in the recovery be provided for lessons that can be taught to lay individuals process.

©FD-Communications Inc. Obesity Surgery,11, 2001 375 Crete Abstracts

5.PREGNANCY AFTER GASTRIC BYPASS. this purpose, each patient is also given a detailed booklet Bobbie Lou T ripp, RN, Melvin S. Swanson, PhD, Paul describing what they have just heard described by the surgeon. Cunningham, MD, Walter Pories, MD, Sharon Shipley, RN, Bret If a patient then decides to proceed with the surgery, he or she Brown, RHIA, Kenneth MacDonald, MD. Brody School of enters the pre-surgical program of our morbid obesity clinic, Medicine, East Carolina University, Greenville, NC, USA which lasts 2-3 weeks and includes a complete physical exam- Background:It is known that obese women who become ination, blood chemistry workup, nutrition evaluation and edu- pregnant are at higher risk for developing obstetric complica- cation, ultrasound of the hepatobiliary system, cardiology, tions and they have a significant incidence of infertility.The pur- endocrinology, pulmonary , and psychiatric evaluations and pose of this study is to evaluate outcomes of patients who other medical evaluations when necessary .Nursing protocol became pregnant after a Roux-en-Y gastric bypass. immediately before and after surgery includes standard patient Methods:Between January 1980 and June 2000, 60 patients preparation and care and administration of prescribed medica- became pregnant after having a Roux-en-Y gastric bypass. tions.Immediately following surgery, the patient stays in the During November 2000, a phone survey located 34 of them and recovery room until stable and alert and is then transferred to they were asked a series of questions about their post-surgery the surgical ward providing no complications occur requiring pregnancy history, pregnancy complications, weight gain during care in the ICU. The patient is mobilized as early as possible, pregnancy, and baby’s birth history. usually on the same day.On the 4th postoperative day a radiol- Results:Of the 34 patients, 21 (62%) were Caucasian and ogy examination is performed to check for any leaks and follow- 13(38%) were African American. The average preoperative ing this, the patient begins postoperative per os feeding and is weight for these patients was 142kg (ranging from 104 to followed by the nutritionist.Most patients are discharged on the 247kg), with a mean BMI of 53.T wenty of the patients reported 6th or 7th postoperative day with full medical and nutritional attempts to get pregnant before surgery and 14 (70%) of these guidelines and return on the 20th day for removal of the staples had difficulty conceiving before surgery .The average time to and further discussion with the nutritionist. Finally , the patient conceive after surgery was 38 months, ranging from 6 months enters the regular postoperative follow-up program with visits to to 9 years.The average age at birth was 33 years, ranging from the outpatient clinic for evaluation at 1, 3, 6, and 12, 18 (BPD 23 to 41 years.Mean weight gain during pregnancy was 10kg, with RYGBP pts) and 24 months following surgery and yearly with 4 patients either losing or not gaining weight.T wenty one thereafter. (62%) were able to return to their pre-pregnancy weight. The Results:From June 1994 to April 2001, 196 patients under- mean percent of excess weight loss for these patients was 46%, went various bariatric surgical procedures at our institution.All with an average follow-up of 13 years.Before the pregnancy, 7 patients followed the specific pre- and postoperative protocol (21%) reported health problems, 19 (56%) reported problems or designed by our Clinic and no patients have been lost to follow- complications during pregnancy, while 8 (24%) reported prob- up.The program is low in cost and relatively easily carried out, lems after the birth.Six (18%) reported diabetes complications and it is our opinion that this program has helped our patients to during pregnancy, while another seven had hypertension.Nine better understand their surgery, to return for scheduled follow- (26%) of the patients, 6 Caucasians and 3 African Americans, up visits, to reduce the incidence of long-term complications gave birth prematurely, while 6 (18%) had one or more miscar- and to have the best possible overall outcome. riages.Six (18%) of the patients reported health problems with Conclusion:Having a specific pre- and postoperative patient their baby. protocol with an organized team approach is essential for the Conclusion: For those women trying to conceive before immediate and long-term success of bariatric surgical patients. surgery, 70% reported difficulty in conceiving .Over half reported health problems during the pregnancy, with the prob- 7.DIET ARY MANAGEMENT OF PATIENTS WITH MORBID lems ranging from minor complaints of edema to more serious OBESITY AFTER VERTICAL BANDED GASTROPLASTY. complications of gestational diabetes and hypertension. The Vassiliki Komessidou, A.Papakonstantinou, P.Alfaras, I.Terzis, rate of prematurity was 23% for the black women and 29% for P.Moustafellos, S. Gourgiotis, S. Brousta, E. Hadjiyannakis. the white women, far exceeding the United States rates of Department of Nutrition and 1st Department of Surgery approximately 13% for nonwhite newborns and 7% for white «Evangelismos» General Hospital, Athens, Greece infants.In addition to prematurity, infant health problems Background:Morbid obesity (MO) is a serious condition included jaundice, respiratory distress syndrome, deafness, requiring surgical treatment. The post-surgical diet of these asthma, aspiration pneumonia, and autism. patients is a necessary supplement of their surgical management. 6.PRE AND POSTOPERATIVE PROTOCOL FOR BARIATRIC Methods: To evaluate the importance of post-surgical dietary SURGICAL PATIENTS. management, 290 patients with MO (64 males and 226 Loukidi Aggeliki, Mead Nancy, and Kalfarentzos Fotis. Nutrition females), age 17-56 years, body weight 107-217 kg, were put in Support and Morbid Obesity Clinic, Surgical Department, a special liquid diet (SLD) after vertical banded gastroplasty University Hospital of Patras. (VBG). Daily intake was 655 kcals:61.4g protein, 91.2g carbo- Background:Patients undergoing surgery for morbid obesity hydrates, 4.9g fat, and vitamins and minerals based on normal need special attention and education both before and after daily requirements.The total quantity of the liquid was 250 ml, surgery in order to ensure the best possible outcome. which was dissolved into 5 meals of 50ml each.The ingestion of Methods:At our institution all patients undergoing bariatric only 50 ml/meal was necessary due to the small volume of the surgery follow a specific pre and postoperative protocol super- gastric pouch. vised and run by the Morbid Obesity team including surgeon, Results:The patients lost 13-28kg and 35-56kg at 1 and 3 nutritionist and nurse. Preoperatively , patients are first fully months, respectively .After 3 months, patients were gradually informed by the surgeon regarding the advantages and disad- put on a regular diet. Ninety (90) patients (21 males and 69 vantages of the surgical option and what exactly is involved.For females) reached their ideal body weight within 12 months,

376 Obesity Surgery,11, 2001 Crete Abstracts while 129 patients (30 males and 99 females) had lost over the are still not completely clarified, specially on the psychiatric 50% of their overweight and were approached their ideal body field.Some psychiatric disorders are currently considered con- weight at the end of the first postoperative year.Plasma choles- traindicative for these procedures, mainly affective, psychotic terol (244 ± 42 mg/ dl), triglycerides levels (171 ± 33 mg/ dl), and personality disorders. VLDL levels (19.32 + 1 mg/dl) were reduced at the end of first The authors describe the case of a 37 years old female sub- postoperative year.(182 + 2 mg/dl, 119 + 72 mg/dl and 17.11 + ject, obese since the age of 12 presenting appetite-suppressant 1,56 mg/ dl, respectively p<0.05). HDL levels (22.13 + 1.23 drug abuse and dependence since the age of 15. mg/dl) were increased (24.22 + 1.16 mg/dl) in the same period. She had a diagnosis of Bulimia nervosa and Borderline Conclusion:Special liquid diets for the first postoperative Personality Disorder (DSM IVTM).That patient was submitted to period after VBG contribute significantly to rapid weight loss and a gastric-bypass operation on August 2000 with BMI 40.2.The reduction of plasma cholesterol, triglyceride and VLDL levels in present BMI is 27.2 and the patient is free of the previous psy- patients with morbid obesity. chiatric symptoms, with adequate response to the regular treatment. 8.COPING STYLE AND EATING PATTERN IN OBESE AND The authors conclude that selected psychiatric morbidly MORBIDLY OBESE PATIENTS WHO WERE SCREENED obese patients may be successfully treated by standard PREOPERATIVELY FOR A GASTRIC RESTRICTION PRO- Bariatric operations.Psychiatric follow up is mandatory. CEDURE. Rogier Hörchner MSc, RN, Wim Tuinebreijer, MD, Ph.D, MSe. 11.ADDICTIONS? ROLE AFTER BARIATRIC SURGERY. Department of Clinical Research Ra-Medic & Dutch Obesity Elisabeth Ardelt-Gattinger, Irene Hofmann, Edda Angermann & Clinic Hilversum, The Netherlands Melodie Moorehead. Psychological Institute of University of Background:Morbid obesity can be seen as a chronic dis- Salzburg, Austria Holy Cross Hospital Ft.Lauderdale, USA ease.Stress can indirectly affect illness by altering a person’s Background:Theories about addictions role in obesity are behaviour patterns like health behaviours.A restrictive bariatric currently in conflict (Ellis et al 1992, Pudel & Westenhöfer 1998). intervention may lead to achieve a permanent modification of Its role is not a purely academic matter, since questions about the eating habits of morbid obese patients.These bariatric inter- its role affect decisions on intervention and therapy before and vention can be seen as a stressful event.T o analyse the rela- after bariatric surgery.In first studies we could prove that 100% tionship between eating pattern and coping style of (morbid) of subjects with a BMI > 40 meet the minimum of three criteria obese patients, the Utrechtse Coping List and Dutch Eating of dependency described in DSM IV.Additionally, we found that Behaviour Questionnaire were used in this study. subjects with a BMI > 40 do not differ significantly from alco- Methods:The present study was set up to analyse the rela- holics and smokers in the factors of our addiction questionnaire. tionship between eating pattern and coping style of (morbid) The question arises, how addiction changes after surgical inter- obese patients who consider a restrictive bariatric procedure. vention, when abnormal food intake is stopped. Coping style was monitored by using the Utrechtse Coping List. Method:To test whether or not obese people with a BMI > 40 Eating pattern was monitored by using the Dutch Eating continue to have addictive structures we tested 254 people (195 Behaviour Questionnaire in 100 (morbid) obese patients. female / 59 male) before (97/33) and after surgery (98/26).The samples were tested with our Addiction scale, the Moorehad- 9.ANESTHETIC CARE IN MORBID OBESITY. Ardelt Quality of Life Questionnaire, and a self-esteem scale. Adrian Alvarez;Antonio Cascardo, Albarracin, Silvio. IMETCO Results:Results show, that quality of life-, self esteem-, and (Multidisciplinary Institute Specialized in the Treatment and the addiction-scores differ significantly between people before and Surgery of Obesity), Buenos Aires, Argentina after surgery.The first 2 scales correlate significantly with weight Morbid obese patients present several anatomic and physi loss after surgery.The addiction score does not correlate with logical impairments. This situations are responsable of the weight loss.BUT when we compared two groups of subjects (a increasing risk of transopera toty complica tions. lot/little weight loss), we found significant differences concerning Anaesthesiologistand surgeons must know about them in order the addiction scale. toprevent their appearence. Conclusion:For the psychological screenings before surgery In this video are shown the principal actions that we have it is of immense importance to take the addiction factor into con- taken(after four years of experience) to improve the patients sideration.Additionally, it is necessary for the time after surgery security. (the critical phase being 6 months after the intervention) to pro- Positioning, monitoring, drugs delivery devices, intubation vide psychotherapy for highly addicted persons who do not lose devices, and postoperative analgesia devices appears, all reg- enough weight istered during different procedures. Incidence of different types of complications are included in a 12.A 15-YEAR EVALUATION OF BPD RESULTS ACCORD- table. ING TO BAROS CRITERIA. Giuseppe M. Marinari, Giovanni Camerini, Federica Murelli, 10.BARIA TRIC OPERA TION IN A PATIENT WITH POSSI- Francesco Papadia, Paola Marini, Cesare Stabilini, Flavia BLE PSYCHIATRIC CONTRAINDICATION-CASE REPORT. Carlini, Nicola Scopinaro. DICMI, Semeiotica Chirurgica R, Azevedo AP ,Libanori HT ,Segal A. Institute of Psychiatry- University of Genoa School of Medicine, Genoa, Italy Hospital das Clinicas-Sao Paolo University Medical School BPD is considered the most effective bariatric procedure. Grade III obesity is considered a chronic disease with poor Nevertheless, even if several studies show a very good weight outcome when treated by conservative approach. The more loss (WL) and maintenance, and a consequent improvement in consistent results tend to be obtained through surgical proce- medical conditions, the expected amelioration in quality of life dures. (QoL) was never reported.BAROS, which takes into considera- The indications and contra-indications of obesity operations tion WL, comorbidities, complications, reoperations, and QoL,

Obesity Surgery,11, 2001 377 Crete Abstracts has proven to be a standard reference in the outcome evalua- Considering morbidly obese patients, bariatric surgery is the tion in bariatric surgery.So as to apply BAROS to BPD subjects treatment of choice.BCP is not effective for this population even (s.), we sent out a questionnaire to 1800 AHS BPD s.which had when associated to other clinical procedures.In spite of that, it been operated on between 1984 and 1998.It was returned and may have an important role as a preparatory routine, consider- filled out correctly by 820 of them (46%);in 91 cases (5%) the ing the magnitude of behavioral changes caused by these oper- letters were returned unopened and in 27 cases (1.5%) the ations. questionnaire was incomplete and could not be used.Out of the Fifteen female morbidly obese patients attended group BCP 820s, 594 were women. Mean preoperative age was 38± 11, sessions on a weekly basis for 6 moths prior to the operation. mean body weight 128 kg ±26, corresponding to a mean per- Psycho-educational strategies including reports from operated centage in excess weight of 118 ± 38.The WL, which is patients were used. At the end of the preoperative BCP expressed as percent loss of the initial excess weight (IEW%L), approach, the patients were widely informed about the opera- both in the unrevised and revised patients, was 69 ±15 at 14 tion itself, risks and consequences. years (60 cases), 66 ±18 at 12 years (131 cases), 68 ±18 at Although further studies are required in order to validate this 10 years (334 cases), 69 ±18 at 8 years (532 cases), 68 ±18 point of view, the cognitive and affective comprehension of the at 6 years (659 cases), 67 ±18 at 4 years (738 cases), and 68 treatment may be better achieved under this method. ±18 at 2 years (800 cases).The mean score attributable to WL was 2.2 ±0.7.Dyslipidemia (376 subjects, 46%), sleep apnea 14.PSYCHOLOGICAL FACTORS AND PATIENT MOTIVES (36 subjects, 4%), obesity hypoventilation syndrome (62 sub- IN RELA TION TO BMI REDUCTION IN MORBIDL Y OBESE jects, 8%) and type II diabetes (118 subjects, 14%) were all PATIENTS FOLLOWING BARIATRIC SURGERY. resolved, whilst hypertension, present in 432 s, disappeared in Vlachos Ioannis O.**, Stergiou Theofilos**, Mead Nancy*, Berati 376 (87%), was improved in 38 (9%) and was unchanged in 18 Stavroula**, Kalfarentzos Fotis*. Nutrition Support and Morbid (4%).Obesity-related comorbidities were absent in 45 s.only . Obesity Clinic, Surgical Department*, and Psychiatric Revisions were 52 (6.3%), which were mainly due to recurrent Department** University Hospital of Patras, Greece. protein malnutrition. The mean score referred to an improve- Background:Psychological factors and patient motives may ment in medical conditions, from which complications and reop- affect the overall outcome of surgery in morbidly obese bariatric erations were deducted, was 2.0 ± 1.1.The mean score patients. obtained by the Quality of Life Questionnaire was 1.0 ±1.5, and Methods:From June 1994 to April 2001, 196 morbidly obese the mean total score was 5.1 ±2.2, which is defined as a very patients underwent various bariatric procedures at our institu- good result by the scoring key.Out of the 820 s., 30 (3.7%) were tion.All patients were assessed psychiatrically before the oper- classified as a failure, 99 (12.1%) were fair results, 219 (26.7%) ation by the same psychiatrist (I.O.V .).In addition, they com- good results, 306 (37.3%) very good results, and 166 (20.2%) pleted the General Health Questionnaire-28 and the Eysenck excellent results.We divided the 820 s.into two groups:the first Personality Questionnaire (EPQ). Finally, they answered a semi- group consisting of 573 before the adaptation of the alimentary structured questionnaire aimed at showing what their main limb to patient’s characteristics, and the second group consist- motives were for deciding to have a bariatric operation in order ing of 247 submitted to the ad hoc stomach ad hoc alimentary to lose weight. limb (AHS AHAL) BPD.The revision rate was 8.6% in the first Results:The results presented here refer to the first 92 group and 1.2% in the second one, while the mean IEW%L was patients undergoing surgery.Personality traits, as described in 68.6 ±18 and 64.3 ±17, respectively;the mean WL score was the EPQ, did not correlate with the reduction of BMI, while 2.23 ±0.7 in the first 573 s.and 2.13 ±0.6 (ns) in the others, the patients psychiatric caseness, as determined by the GHQ mean QoL score was 0.9±1.5 and 1.3 ±1.3 (p < .001), respec- score, was associated with the most marked reduction in BMI tively, and the mean total score was 5.0 ±2.2 and 5.5 ±2.0 (p after the first and the second year of follow-up.The strongest =.002).According to the scoring key, we had a 4.5% failure rate motive for wanting to lose weight was, for men the diminished in the first group and a 1.6% failure rate in the AHAL group, ability to perform their daily activities and for women the body while 14% and 7.7% of the cases, respectively, were fair results, image disparagement.Y ounger patients tended to state dissat- 27.2% and 25.5% good, 34% and 44.9% very good, and 20.2% isfaction with their weight and shape as their primary motive for of both groups excellent results. surgery, while elderly people were more concerned with health Adapting gastric volume and intestinal lengths to the patient problems. characteristics has decreased the incidence of metabolic com- Conclusion:Psychological status and patient motives seem plications, thus leading to a sharp fall in the need for surgical to play a part in the BMI reduction after bariatric surgery, while revision.BAROS evaluation of BPD highlights the importance of personality does not.Women and younger people have different its flexibility:the new policy of tailoring the procedure to individ- motives for undergoing bariatric surgery than men and older ual characteristics caused a drop in the failure rate and an patients. increase in good, very good and excellent results (90.6% of the total).Particularly , the increase in the QoL mean score shows 15.THE EFFECTS OF GASTRIC BYPASS SURGERY ON greater patient satisfaction, despite the lower WL. MEASURES OF PSYCHOLOGICAL DISTRESS. Mary Gallacher, M.B., Ch.B., Cynthia Buffington, Ph.D ., and 13.PREOPERA TIVE BEHAVIORAL-COGNI TIVE PSY- George S.M. Cowan, Jr., M.D. The University of T ennessee CHOTHERAPY FOR BARIATRIC SURGERY PATIENTS. Health Science Center, Department of Surgery and The Clinical Mingardi A, Crozeta G, Larino MA, Libanori HT , Segal A. Research Center, Memphis Tennessee, U.S.A. Institute of Psychiatry-Hospital das Clinicas-Sao Paolo Background:Our previous studies found a high degree of University Medical School depression and anxiety among morbidly obese (MO) bariatric Behavioral-cognitive psychotherapy (BCP) is widely recog- surgical candidates.The purpose of this study was to examine nized as one of the cornerstones on the treatment of obesity. the influence of weight loss following gastric bypass (GBP)

378 Obesity Surgery,11, 2001 Crete Abstracts surgery on these measures of psychological distress. Following GBP, total body weight declined from an average of Methods:The study population included 99 MO GBP surgical 135 kg pre-op to 113, 92, 80, and 75 kg at post-op months 1-3, candidates, mean weight = 135 ±2.9 kg (range = 90-212.9 kg), 6-9, 12, and ³ 24, respectively.BDI scores fell by 58% within the mean BMI = 50.5±1.1 (36.2-80.7), waist circumference = 47.1 ± first 1 to 3 post-op months (19.8 to 8.3) and did not significantly 0.7 cm (34-66 cm) and average age = 41 ±1.1 yrs (range = 21- change thereafter.BAI scores declined by 54% during the first 6 73 yrs).Depression and anxiety were measured by the Beck to 9 post-op months (13.8 to 6.3) but returned toward pre-op val- Depression and Anxiety Inventories (BDI and BAI, respectively) ues by the 24 month observation period.Post-op changes in before surgery and at postoperative (post-op) periods 1-3, 6-9, ³ anxiety or depression following GBP were not significantly 12, and ³ 24 months. Results:Prior to GBP, 80% of the MO population were clini- (>0.05) correlated to changes in body weight or other anthropo- cally depressed and 61% had high anxiety.Pre-op BDI and BAI metrics. scores were highly correlated (r=0.69, p<0.0001) but neither of Conclusions :GBP transiently improves levels of anxiety these measures of psychological distress were significant among MO patients and has a sustained salutary influence on (p>0.05) correlates of body weight or other anthropometrics. depression. 3rd International Symposium on Laparoscopic Obesity Surgery (ISLOS)

16.LAP BAND, CHANGES IN SURGICAL TECHNIQUE: 10/12 mm for open laparoscopy and the optics, 10 mm for the OUTCOME OF 1410 SURGERIES PERFORMED FROM JULY liver retractor, 5 mm and 15 mm for dissection and insertion of 1995 THROUGH APRIL 2001. the prosthesis. Jean-Marie Zimmermann, Michel Blanc, Pierre Mashoyan, Érick In this way, the authors hope to contribute to improving the Zimermann, Jean-Marc Grimaldi. Clairval Private Hospital results with the laparoscopic gastric banding technique, which, Center, Marseille, France despite its drawbacks, is effective and still remains the least The authors present the changes in their technique for place- aggressive and most easily reversible technique for the surgical ment and fixation of adjustable gastric bands. treatment of morbid obesity. From July 1995 through December 1999, 1145 patients underwent surgery.The identical technique was used from the 17.PROXIMAL GASTRIC BANDING AFTER F AILED GAS- start:laparoscopy, 5 trocars, calibration balloon inflated with 15 TRIC RESTRICTIVEOPERATIONS. cc, position in contact with the stomach, band fixed with three Eliezer Avinoah, MD, Solly Mizrahi, MD, Leonid Landsberg, MD. sutures through the stomach, above the band. The sutures in Surgery A, Soroka Medical Center, Faculty of Health Sciences, the splenic region were also placed through the left crus of the Ben-Gurion University, Beer-Sheva, Israel diaphragm.Therefore, the materials used were the LAGB with Between 1980 to 1985 624 patients had Roux en Y gastric the original technique in 1090 cases and the SAGB in 55 cases. bypass operation. From 1986 vertical gastroplasty was per- We felt that the 11% slippage complication (up to 18% in the formed in 1300 patients.We began to perform open and lapar literature) was unacceptable.This occurred in the series of 1090 scopic gastric banding for the last four years. LAGB cases. One-hundred twenty-nine cases underwent 46 patients were re-operated after failed gastric restrictive laparoscopic reoperation (seven patients had two successive surgery for morbid obesity.Their mean age was 44±9 years old slippage events). (34 to 67 years) and their BMI (body mass index) was 41±4. In addition to a new approach to positioning the prosthesis, Seven (15%) patients had previous Roux en Y gastric bypass all in pars flaccida position (LAGB 10.0cm, 103 cases; LAGB and 39 (85%) patients were after vertical gastroplasty .The 11.0cm, 123 cases;SAGB, 50 cases), a new method of pros- patients after gastric bypass surgery had enlarged gastroje- thesis fixation was used. junostomy.39 (80%)patients aftergastroplasty were reoperated The idea is to immobilize the region located between the because of stapled line disruption , two(5%) had enlarged band and the diaphragm.Three sutures are used for this fixa- banded stoma, and six (15%) had nutritional restriction intoler- tion: ance.The average time elapsed from the first surgery was 6±7 - Left, fixing the stomach (fundus of the stomach), below the years(3 to17 years).Patients had open or laparoscopic surgery band, to the left crus of the diaphragm at which adjustable gastric band was inserted retroperi- - Medial, stomach below the band, stomach above the band tonealyfrom the angle of Hiss to the lesser curve at the level of - Right, fixing the stomach (lesser curvature of the stomach), the caudate lobe of the liver.Mean operative time was 115±25 below the band, to the right crus of the diaphragm minutes and hospital stay was two days after open surgery and Thus the region is well closed and the band is fixed, but not one day after laparoscopic surgery .Two patients had wound blocked.There is no longer any expansion space above these infection and five had postoperative hernia. There was no sutures and the diaphragm, as was the case with the original mortality.a mean of three years after surgery the mean BMI is technique. 25±6. We conclude that proximal gastric banding is a safe and Admittedly there has been insufficient follow-up time, but effective operation both for gastric bypass and for vertical gas- since January 2000, there has been no slippage in the 278 troplasty. patients who received this type of surgery .During that same period, there were 27 occurrences of slippage with the original 18.TECHNICAL MODIFICATION IN LAP-BAND IMPLANT technique. Casalnuovo Carlos Alberto, Ochoa de Eguileor Ezequiel, Finally, placement of the band requires only four trocars: Parrilla Gustavo, More Marco. Hospital de Clínicas, University

Obesity Surgery,11, 2001 379 Crete Abstracts of Buenos Aires, and Private Practice (CCO-Centro de Cirugía 195) and a mean B.M.I.of 43,9 Kg/m2 (35,1-65,8).157 patients de la Obesidad), Buenos Aires, Argentina. had no comorbidity and the 293 remaining had 1,48 comorbid- Background:The adjustable Lap-band, requires a simple ity each due to weight excess. technique, with minimal morbidity. Results:There was no death.The mean operative time was The pouch volume and the stoma diameter, are the two main 111,9 minutes (30-380), the mean hospital stay was 4,5 days factors that regulate the weight loss. (3-42).There were 12 conversions (2%), 8 among the 50 first The surgical technique and the procedure have to be optimal procedures.46 complications required an abdominal reopera- and effective. tion (10%) for perforation (n=4),necro sis (n=1), slippage Methods:After the learning curve (30 operations) we intro- (n=33),reconnection of the tube (n=6) and incisional hernias duced some modifications to the technique and the procedure, (n=2).We noticed 7 pulmonary complications (2 ARDS, 5 which are shown on the VIDEO. atelectasias) and 35 benign port problems (30 rotations and 5 1 - better dissection of the left crus of the diaphragm and of the infections ).Slippage happened as a prolapse of the stomach left esophagus-gastric junction. through the band ; it was the main late complication (at 11,3 2 - the beginning of the tunnel dissection, is carried out at a months, range 4-22) and required changes in the surgical pro- higher level.The stomach is separated from the inferior part of cedure (pars flaccida approach)and in the device itself. After the right crus in a subcardial level.The perigastric fat is included four years 30 patients had no longer the band (6%), 15 have trying to separate the pneumogastric nerve.The whole dissec- been lost to follow-up (3%).Among the 405 followed during a tion is in the phrenogastric ligament thickness. mean time of 12,03months (0-43), in three years B.M.I.fell from 3 - the “gastrostenometer”is not used anymore. 43.9 to 30.3kg/m 2 and mean E.W.L.reaches 61.9%.3 patients 4 - a better anterior gastric wall fixation with more sutures over among 55 (5%) had an E.W.L.under 20% after three years.The the band (gastrogastric and gastrodiaphragm). 65 superobese-patients (B.M.I. above 50 kg/ m2) obtained an 5 - the radiological control with hydrosoluble solution before dis- inadequate B.M.I: 42.3 kg/ m 2 after 1 year (n=31) 37.2 kg/ m 2 charge from hospital is used in selective form. after 2 years (n=24), which does not prevent them from vital Results:Of the 150 operated on patients, two slippages were complications of their obesity.43 patients still have no balloon developed.One anterior needed relaparoscopy 4 1/ 2 months inflation, 201 patients (47%) had one ,the 176 others required later, with gastric wall reduction and new fixation.The other one, two (n=117),three (n=44), four or more (n=15) readjustments. posterior, in that was used the original perigastric technique in Conclusion:Our experience with Lap-Band is encouraging the primary operation, it was partially corrected with band defla- without mortality , with an acceptable complication rate. If we tion, carrying out a higher and more stable repositioned new exclude superobese patients for whom this operation seems to band by relaparoscopy 16 months later.No gastric lesions and be inadequate, more than half of weight excess can be lost in no mortality .The surgical time is reduced to 75 min (40-120), three years, with comfort , which has never been obtained by doing easier the dissection, especially in patient with BMI = / any medical treatment. But the procedure is still evolving and >60. the whole medico-surgical staff has to stay close to each Conclusions :With the modificat ions was achieved: 1) patient. decrease surgical time, 2) better cost/ effectiveness, 3) more simple dissection in patients with BMI=/>60, 4) create a virtual 20.LAP AROSCOPIC GASTRIC BANDING: WHY pouch at the beginning, with a very small size later, 5) obtain a CHANGING TO ANOTHER TECHNIQUE? higher and stable band position, that prevent the posterior slip- Ahmed Zayed, MD, Mohammad Al-Jarallah, MD. Armed Forces page, and also decreases the possibilities of instrumental Hospital Kuwait, State Of Kuwait. lesions on the posterior gastric wall.The best fixation with gas- Background:Many authers consider gastric banding as the trogastric and to the diaphragm crus sutures contribute to avoid first choice for the surgical treatment of morbid obesity, because the anterior slippage, 6) decrease the morbidity, avoiding com- it is reversible and can be performed laparoscopically.But at the plications. same time reported morbidity like gastric perforation, band slippage and pouch dilatation are causes for some concern. 19.LAP-BAND GASTRIC BANDING IN APUBLIC UNIVER- Methods:We started laparoscopic gastric banding in our hos- SITY HOSPITAL: SUCCESS AND PITFALLS WITH 450 pital from February 1999 using the Lap Band (AGB, PATIENTS IN FOUR YEARS. Bioenterics).We inserted the band for 69 patients laparoscopi- Jean-Marc Chevallier, Franck Zinzindohoue, Jean-Philippe cally using the retrogastr ic dissectio n technique. From Blanche, Richard Douard, Jean Louis Berta, Jean Jacques September 1999 we started to use our safe and easy technique. Altman, Paul-Henri Cugnenc. Departments of Surgery and We inserted the band for 55 patients using this technique. Nutrition.Hô pital Europpéen Georges Pompidou, 20-40 rue Results:After using our new technique we eliminated most of Leblanc 75908 PARIS cedex 15, France the complications of retrogastric dissection technique like gas- Background:Laparoscopic approach is gaining widespread tric perforation and pouch dilatation. acceptance as a gastroplasty for morbid obesity .Adjustable Conclusion:Our technique is simple and safe guarantees a gastric banding is a restrictive procedure considered as less stable and high band position. Our intermediate results are invasive and potentially reversible , which could guarantee a good. better quality of life.In our consecutive series of 450 patients we evaluated prospectively complications and followed Excessive 21.MODIFIED LAPAROSCOPIC VBG FOR TREATMENT OF Weight Loss (E.W.L.) since four years. MORBIDLY OBESE PATIENTS. Methods:from 04/1997 to 04/2001, 450 patients have been J.Melissas, G.Schoretsanitis, J.Grammatikakis, D.Michaloudis laparoscopically operated on for severe obesity according to and D.D.Tsiftsis. Bariatric Unit, Dept. Surgical Oncology. N.I.H.criterias : 390 women, 60 men, with a mean age of 40,4 University Hospital, Heraklion, Crete, Greece. years (16 – 66),a mean preoperative weight of 119,7 Kgs (85 – Background:This study compares, as far as early outcome is

380 Obesity Surgery,11, 2001 Crete Abstracts concerned:a) the Laparoscopic VBG procedure, as originally The weight development corresponds to a 50% reduction of performed (Mason-Mclean type), with creation of gastro – gas- excess body weight after 1-2 years postoperatively.Thereafter trostomy, division of the gastric pouch and Marlex mesh place- you find a tendency to weight regain.About 1/3 of the patients ment, by suturing it to itself and b) a modification of the proce- reported vomiting most often due to overeating. dure, by Wedge resecting part of the fundus, avoiding the gas- Conclusion:Laparoscopic VBG can be carried out with low tro-gastrostomy and application of the Marlex mesh, with clips perioperative morbidity, short hospital stay and fast recovery. using the EndoGIA ® (Tyco) instrument. The weight development and the frequence of re-operation as Methods:36 morbidly obese patients were included in this well as the postoperative eating disturbances seems to be com- retrospective study .Group A: consisted of 18 patients with parable to what earlier has been presented in series with open Gastrogastrostomy, sutures to marlex and using the Endostich ® surgery. instrument (T yco) and Group B: consisted of 18 patients with Wedge resection of part of the fundus and EndoGia ® (Tyco) to 23.LAP AROSCOPIC VERTICAL BANDED GASTRO- secure marlex in place. Operative time, conversion rate, intra PLASTY:RESULTS ON 250 CASES WITH 5-YEARS FOL- and postoperative complications, pain and hospital stay were LOW-UP. assessed. Mauro Toppino, MD, Mario Morino, MD, Danilo Donati, MD, Luca Results: Mazza, MD, Valeria Costamagna, MD. Department of Surgery, Group A Group B University of Turin, Italy 1.Operative time (mean)155 min 115 min Background:The advantages of laparoscopic approach in 2.Bleeding 2 Pts ——- morbidly obese patients have been demonstrated, in particular, 3.Conversion 2 Pts ——- with the ASGB, but this operation still presents a high rate of 4.Pain (Visual analog) 3 3 late complications; gastric by-pass or malabsorbitive proce- 5.Atelectasis 3 Pts 1 Pt dures are feasible by laparoscopy but involve prolonged opera- 6.Pneumonia 1 Pt ——- tive time and a consistent morbidity rate. Laparoscopic VBG 7.Leak 0 0 could represent an effective alternative. 8.Hospital stay 3 days 3 days Methods:300 laparoscopic VBG with complete division Conclusions :Laparoscopic modification of VBG by Wedge between the staple lines were performed since November 1995. resection of part of the fundus, thus avoiding gastro-gastros- The following results are related to the first 250 cases with a 1- tomy and the use of Endo-GIA to secure the Marlex reinforce- 5 years follow-up. Average age was 39.3 years, mean weight ment of the gastric outlet in place, significantly decreases oper- 120.1 Kg, excess weight 209.1%, BMI 45.1 Kg/ m 2.Forty-four ative time and reduces early complications.Therefore it is the patients (17.4%) were superobes e.Conversion to open most preferred method for laparoscopic vertical banded gastro- occurred in 2 case (0.8%).Five cases were conversions to VBG plasty for treatment of morbidly obese patients. of a previous LASGB (4) or a laparoscopic gastric banding (1). Mean operative time was 95 min.(range 50-210).An associated 22.LAPAROSCOPIC VERTICAL BANDED GASTRO- operation was performed in 59 cases (23.6%):cholecistectomy PLASTY (VBG) - LONG-TERM OUTCOME IN 139 PATIENTS. (34 cases), adhesiolysis (15 cases), hiatoplasty (2 cases), Torsten Olbers, Hans Lö nroth, Jan Dalenbä ck*, Eva Haglind, umbelical hernia repair (2 cases), band removal (5 cases), cys- Lars Lundell. Department of Upper G-I Surgery , Sahlgrenska togastrostomy for pancreatic cyst (1 case). University Hospital and *Frolunda Specialist Hospital, Results:Operative mortality rate was nil.Early complications Gothenburg, Sweden. were 11/250 (4.4%):1 leak (reintervention), 5 bleedings (trans- Background:VBG is a established restrictive bariatric opera- fusions), 3 temporary outlet substenosis (medical therapy), 1 tion that has been frequently used during the last decades.The subphrenic collection (medical therapy), 1 pulmonary embolism. operation has since 1993 been performed by use of laparo- Late complications were 10/ 250 (4%): 1 food intolerance for scopic technique at Sahlgrenska University Hospital.The long- poor compliance, 1 outlet stenosis with collar erosion (VBG term outcome of these patients is hereby presented. takedown by laparoscopic approach in both cases), 1 "cascade" Methods:During the period October 1993 to December 1999 pouch with antideclive outlet (conversion in gastric by-pass by 139 consecutive patients were operated on with a laparoscopic laparoscopy), 4 cases of severe solid food intake troubles (1 VBG. Perioperative datas were collected. The patients has conversion to lap gastric by-pass), 2 pouch enlargement with thereafter been followed regularly with respects to weight devel- gastro-oesophageal reflux (1 conversion to lap gastric by-pass), opment, complications, re-operations and eating disturbances. 1 sudden death (m.i.) at one year (patient with poor weight Results:Six patients were converted to open surgery due to loss).Excess weight loss was:60.3% at 1 year (194 p), 64.6% a large steatotic left liver lobe.Three patients were re-operated; at 2 years (121 p), 63% at 3 years (59 p), 61.1% at 4 years (26 one due to leakage, one due to suspected leakage and one p), 56.8% at 5 years (11 p).According to Reinhold classification where the ventricular tube was caught in the vertical staple line. (residual excess weight <50%) a success was achieved in The mean operation time was 148 minutes (40-315), mean hos- 76.9% of the patients after 4 years, without failures; residual pital stay 3 days (1-13).Both these have been reduced during BMI was 29.4 at 4 years. the study period. Eleven patients had a redo procedure. Five In morbid obese patients EWL at 4 years was 62.2% (22 p), patients could be considered as primary failures as they never while in superobese EWL was 54.9% (4 p); the success rate lost weight sufficiently postoperatively.Three of these had a too was 77.4% in morbid and 50% in superobese;residual BMI was large pouch as probable cause.One patient has been dilated 28.4 in morbid and 35.5 in superobese. because of stoma stenosis and another had a verified band Conclusions :The results on weight loss after laparoscopic migration yet without re-operation. In the secondary failures VBG compare favourably with literature data and personal data (n=6) has pouch dilatation been the cause in two cases and sta- previously reported on 218 "open" VBG. The complications rate ple insufficiency in two. Unclear mechanism in the other two. is low.Considering these results and the wide reduction of peri-

Obesity Surgery,11, 2001 381 Crete Abstracts operative risks due to the coelioscopic approach, the laparo- reviewed for details of the operation, post-operative recovery scopic VBG is, in our opinion, a safe and effective technique in and weight loss during follow up. selected morbid obese patients (excluding patients with com- Results:Between March 1999 and April 2001 we performed pulsive or sweet eating patterns). On the contrary, results on laparoscopic gastric stapling on 17 patients (15F:2M), 11 of superobese patients or in patients with compulsive eating are whom had a sleeve gastrectomy.The median pre-operative BMI questionable:in these cases a more complex procedure (i.e. was 52.1.There were no conversions to open surgery and there gastric by-pass or BPD) should probably be preferred. was no mortality.Morbidity occurred in 6 patients (2 staple line leaks, 1 chest infection, 2 port site infection).The median post- 24.LAPAROSCOPIC VERTICAL BANDED GASTRO- operative hospital stay was 4.5 days.The median BMI at 1, 3, 6 PLASTY WITH ADJUSTABLE BAND IN THE TREATMENT OF and 12 months was 47.7, 43.4, 40,0 and 33.6 respectively. MORBID OBESITY. Conclusion:Laparoscopic vertical gastric stapling is an effec- Giovanni Natalini, MD, Francesco Guiggi, MD, and Luca tive anti-obesity operation, which compares favourably with Calzoni, MD. Department of Surgery, Marsciano-Todi Hospital, open gastric stapling.Resection of the redundant gastric fundus Marsciano, Italy does not add morbidity to the procedure. Background:The adjustable silicone band connected to a subcutaneous port improves both early and late results of 26.THE GAGNER TECHNIQUE FOR LAPAROSCOPIC laparoscopic vertical gastroplasty in the treatment of morbid GASTRIC BYPASS: TECHNICAL OBSERVATIONS AND obesity.Vertical banded gastroplasty for treatment of morbid DETAILS (Video). obesity is our procedure of choice over malabsorbitive opera- Luigi Angrisani; Michele Maresca; Vincenzo Borrelli, Gaetano tions because it maintains normal digestion and absorption Cimmino, Monica Ciannella Institution:Unit of Endoscopic while eliminating the complications unique to exclusion opera- Surgery, “S.Giovanni Bosco”Hospital, Naples, Italy tions.The addiction of laparoscopy and an adjustable collar has The Gagner technique for Laparoscopic Roux-en-Y Gastric further improved the operation. Bypass (LRYGB) has been considered the preferred surgical Methods:From March 1997 through April 2001, 526 severely method to start clinical experience with this procedure.Part 1 of obese patients underwent laparoscopic adjustable vertical this video shows cases in which Blue Methylene Test proved a banded gastroplasty ( Lap-AVBG).The operation uses a ten-cm leakage of the gastroenteric anastomosis: laparoscopic suc- long vertical, stapled and divided pouch with the adjustable cessful repairs and the single case which was converted to band for a collar.The collar is left open and then after 6 weeks laparotomy are presented. Part 2 collects various options we for healing, the lumen is decreased as required to provide a 2- have employed to close the service jejunotomy of the mechani- kg per month weight loss. cal anastomosis obtained by laparoscopic linear stapler device: Results:There have been no operative deaths. There were continous 3/0 silk suture with intra-corporeal knots;interrupted three leaks of the staple line.Four patients had enlargement of 3/0 silk suture with intra-corporeal knots;interrupted 3/ 0 the pouch from slippage of the collar.This was corrected and Polyglactin 910 suture with extracorporeal knots;continous 3/0 subsequently prevented by imbrication of the stomach wall over PDS suture lapra-ty;laparoscopic linear stapler.Gastro-enteric the band anteriorly.Three bands migrated in to the lumen.Four anastomosis and jejuno-jejunostomy are the main steps of infections occurred around the injection port and one of these LRYGB.Complications of these anastomosis may require re- was removed.Seven operations (1.3%) were converted to the operations leading to potentially lethal conditions.Part 3 of the open approach. Mean weight loss was 25.79 kg at one year, video contains frames of relevant episodes of bleeding and the 37.28 kg at two years and 39.51 at three years.Excess weight techniques used to control them. Bleeding was another com- loss was 45.52% at one years, 58.20% at two years and 61.82% mon problem encountered during the operation.Although it has at three years. not been a cause of laparotomic conversion, bleeding has pro- Conclusion:Lap-AVBG makes use of each patient’s needs in longed the operative time. calibration of the outlet.This obviates staple line disruption and pouch dilatation from outlet obstruction.The operation is simple, 27.LAP AROSCOPIC ROUX-EN-Y GASTRIC BYPASS WITH safe,and easy for the patient.The average weight loss achieved SILASTIC RING (CAPELLA´S PROCEDURE) IN THE TREAT- at two years is maintained at three years. MENT OF MORBID OBESITY : TECHNICAL DESCRIPTION IN VIDEO. 25.LAP AROSCOPIC LONG VERTICAL GASTRIC STA- Thomas Szegö , MD, PhD; Arthur B. Garrido Jr. MD, PhD; PLING ±SLEEVE GASTRECTOMY FOR THE TREATMENT Mitsunori Matsuda, MD, PhD; Carlos José Lazzarini Mendes, OF MORBID OBESITY. MD;Marcelo Roque de Oliveira, MD;Alexandre Elias, MD;Luiz Simon PL Dexter, Michael J McMahon. Nikos Georgopoulos Vicente Berti, MD . Private Practice - Albert Einstein and Leeds Institute for Minimally Invasive Therapy , The General Beneficência Portuguesa Hospital, São Paulo- Brazil Infirmary, Leeds, UK The introductio n of laparoscop ic approach to bariatric Background:Long vertical gastric stapling without a band surgery brought similar advantages as seen in general surgery. (Magenstrasse and Mill operation) is a safe and effective restric- Performing Roux en Y gastric bypass according to the regular tive procedure for the treatment of morbid obesity.The proce- techniques however, showed less weight loss then achieved in dure can be performed laparoscopically.The better access thus the open procedure using silastic ring. afforded also allows the redundant stomach to be safely In order to get similar results as in open Capella´s procedure, removed (sleeve gastrectomy).In this paper we present our ini- the authors introduced similar technique through laparoscopic tial experience with laparoscopic vertical gastric stapling proce- approach. dures. The selection of patients is done according to the BMI and Methods:All patients who had laparoscopic bariatric surgery type of fat distribution. were entered prospectively onto a database.The database was Patients with more then 55 in BMI and with typical central fat

382 Obesity Surgery,11, 2001 Crete Abstracts distribution are submitted to open “ Capella”procedure and anvil transorally using a pull-wire technique.In the second group those that are below 55, with non central fat distribution are indi- the gastrojejunostomy is fashioned with a totally hand-sewn cated to laparoscopic Roux en Y gastric by pass. technique.In the third group the gastrojejunostomy is performed In this VIDEO, the authors present technical details of the with an endo-cutter cartridge and the anastomotic incision is procedure. closed with an endo TA stapler. Results:The results were nearly identical in the three groups, 28.LAP AROSCOPIC ISOLATED ROUX-EN-Y GASTRIC BY- Average excess weight loss at one year was 70%. The mean PASS: PRELIMINARY EXPERIENCE. operating time was (120 min) in the first group, (100 min) in the A.Restuccia, D. Polito, G. Silecchia,A.Genco, U. Elmore, N. second group and (75 min) in the third group.Esophageal injury Perrotta, F.Greco, P.Fabiano, N.Basso. Dipartimento di chirur- was the commenest problem in the first group.Incidence of gas- gia “Paride Stefanini”- P oliclinico “Umberto I” Università “ La trojejunostomy stenosis was heigher in the second group Sapienza”Roma (36.6%).Incidence of internal hernia was heigher in the second Background:Roux-en-Y Gastric Bypass has became the gold (17%) and first (13.6%) groups than in the third group (3.3%). standard in USA, due to the well established long term results, Conclusion:Whatever the technique of constructing the gas- including improvement and/ or resolution of comorbidities. On trojejunostomy, laparoscopic RYGBP is a safe, effective and the basis of our experience on advanced laparoscopy, following technically feasible modality for morbid obese patients.We rec- the technical pittfalls described by Gagner, we started our expe- ommend the technique of constructing the gastrojejunostomy rience with Laparoscopic Isolated Roux-en-Y Gastric Bypass with an endo-cutter cartridge and closing the anastomotic inci- (LRYGB). sion with an endo TA stapler as it saves time and reduces the Methods:the multidisciplinary patients selection was based incidence of the essential complications in gastric bypass on the following inclusion criteria: BMI 50-59 (<50 plus dia- surgery. betes);failure of previous restrictive bariatric procedure. From January ‘00 to March ‘01, 14 (4 M, 10 F) consecutive patients 30.FUNCTIONAL GASTRIC BYPASS. underwent LRYGB.Mean age 36 (24-53) years;mean BMI 52.6 Francesco Furbetta, G.Gambinotti. Ospedale di Pescia, Pescia, (48-59) kg/m2.One patient had a previous LASGB failure.the PT, Italy patients presented diabetes. The procedure was performed in Background:Surgery is the only solution for pathological obe- according to the technique reported by Gagner:six trocars were sity.The problem is which operation, for which patient? used;15ml isolated gastric pouch from the distal pouch;division Gastrorestrictive procedures, malabsorptive and gastrointesti- of proximal jejunum 50cm from Treitz;antecolic and antegastric nal by-pass operations all have selection criteria, results, spe- Roux limb (100cm) with end-to-side gastro-jejunal anastomosis cific effects and side effects which can be matched with vari- using 25 EEA stapler;stapled side-to-side jejunojeunostomy. ables like the individual’ s adaptation and psycho-physical Results:The mortality was nil.Only 1 patient was converted response to modifications of lifestyle, dietary rules and restric- to laparotomy due to technical problems of anvil position. tions, and to the primary and secondary effects of each opera- Except the converted case, the mean operative time was 338 tion.Flexibility and adaptability are indispensable to create a (240-480) minutes. 3 patients developed early post-operative bond between the technique proposed and the patient if good complications:wound infection (converted case); prolonged results are to be obtained;since they are hard to define in the ileus;gastro-jejunal fistula (successfully treated with TPN).One patient, they must be offered by the technique.In the light of this patient was reoperated 4 months after surgery due to occlusion we have devised the functional by-pass, which can be activated of the biliary limb (trocar site hernia). The pre-operative BMI and de-activated by inflating or deflating the Lap-Band. decrease from 52.6 (48-59) to 31.3 (29.6-33.1) respectively at 6 Methods: Positioning of the Lap-Band according to the stan- and 12 months after surgery. dard technique, with the addition of hand-sewn side-to-side gas- Conclusions :LRYGB is an advanced laparoscopic procedure troenterostomy between the gastric pouch and the intestine in requiring a specific learning curve. The present preliminary the form of an Omega loop;inflation and deflation of the Lap- experience confirms that LRYGB induce a rapid control of dia- Band allow activation and de-activation of the by-pass.October betes and other obesity related morbidities. 1995 April 2001 495 lap-band;between January 2001 and April 2001 we performed functional bypass operations on 3 patients 29.LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS- with zero morbidity and mortality.Indications:1) After failed Lap- EVALUATION OF THREE DIFFERENT TECHNIQUES. Band treatment.2) May be the first choice operation for patients Essam Abdel Galil, Alla Abbass Sabry**. Department of indicated for malabsorptive bariatric surgery.Advantages of the surgery, Ahmed Maher T eaching Hospital* and Ain Shams procedure:1) Laporoscopic approach 2) Reproducibility 3) University**, Cairo, Egypt. Reversibility 4) Reduced operative and perioperative risks:a) no Background:The Roux-en-y gastric bypass (RYGBP) is one cutting and suturing of gastrointestinal tissue b) no excluded of the ideal operations for morbid obesity.The minimal invasive limbs c) no cutting of mesenteric structures. laparoscopic technique have been performed to shorten the Results and Conclusion :The chance to activate or disactivate operative time and to reduce the complication rates of the open the bypass itself (whether short or long) allows regulation of the surgery. results and modification of the side effects 2) The chance to Methods:During the period from Jan 1999 through Jan 2001 transform the Lap-Band into a by-pass operation upgrades it to an attempt was carried out to perform laparoscopic RYGBP in a first-choice procedure.In the field of pathological obesity char- ninety patients.The median age was 30 with a median preoper- acterised by an abnormal and variable relationship with food, ative BMI of 47.The preoperative nutritional habits and comor- the flexibility of the functional by-pass operation allows it to bidities were recorded. Laparoscopic RYGBP was done by adapt to changes in the pathology itself and in the individual three different techniques in three equall groups. In the first patient, which other surgical techniques cannot do.Surgical via- group the gastrojejunostomy is constructed by passing the EEA bility and safety have been shown but long-term efficacy is still

Obesity Surgery,11, 2001 383 Crete Abstracts to be demonstrated. Estimated blood loss was significantly less in the laparoscopic group (p<0.005). Length of hospital stay was on average 3.9 31.A COMPARATIVE STUDY IN PERCENTAGE OF WEIGHT days for the laparoscopic group and 5.8 days for the open GBP LOSS BETWEEN LAPAROSCOPIC AND OPEN ROUX-EN-Y group, but this did not approach statistical significance (p=0.16). GASTRIC BYPASS. Overall mortality was < 1%, with one death in the laparoscopic Constantine P.Spanos, MD,Edward Salzmann, MD, Christa M. group.Morbidity was 21.4% overall, with 18% in the laparo- Triglio, P A-C Scott A. Shikora, MD. New England Medical scopic group, and 3.4% in the open group. Complications Center, Boston, MA, USA included:anastomotic leak, stricture, bowel obstruction, and Background:Laparoscopic Roux-Y gastric bypass is becom- wound infection.Follow up to 6 months revealed no significant ing a routine procedure for the treatment of morbid obesity.Few difference in weight loss based on operative technique. comparative studies between laparoscopic Roux-Y gastric Conclusions :Laparoscopic Roux-en-Y gastric bypass is as bypass (LGB) and open Roux-Y gastric bypass(OGB) have effective in achieving weight loss as open GBP, while reducing been published.The purpose of this study was to evaluate the operative blood loss and potentially recovery time.Longer oper- percentage of weight loss at the end of the first postoperative ative time and higher morbidity may reflect the learning curve of year after LGB and OGB. this complex laparoscopic procedure. Methods:From December 1998 to April 2000 we retrospectively collected data on 39 patients who underwent LGB and 39 33.LAP AROSCOPIC REOPERATION FOR EARLY COMPLI- patients who underwent OGB. The two groups were sorted for CATIONS OF LAPAROSCOPIC GASTRIC BYPASS. age, gender, body mass index (BMI), perioperative complica- P.Papasavas, M.S. O’ Mara, D. Heathaway, P .F.Caushaj, D. tions, length of stay (LOS) and weight loss. Gagne. Department of Surgery , The Western Pennsylvania Results:The mean age in the LGB group was 37.31 ±9.67 Hospital, Temple University Clinical Campus, Pittsburgh, years vs 43.22 ±9.51 years in the OGB group.The mean pre- Pennsylvania, USA operative BMI in the LGB group was 42.95 ± 3.29 kg/ m 2 vs Background:Laparoscopic Roux-n-Y gastric bypass is con- 45.87 ±4.19 kg/m 2 in the OGB group (p=NS).The preoperative sidered the gold standard procedure for morbid obesity.Early comorbidity and earlier abdominal surgery were similar in the complications can be treated successfully with a laparoscopic two groups.None of the patients in either group required a stay approach.We reviewed our experience with laparoscopic rein the intensive care unit.The mean length of stay in the LGB exploration in the early post-operative period. group was 4.47 ± 0.81 days vs 3.85 ±0.67 days in the OGB Methods:The initial 85 patients who underwent laparoscopic group (p=0.12).There was no 30-day mortality in either group. Roux-n-Y gastric bypass by a single surgeon at a training hos- At 1-year follow-up, the percentage of excess weight loss pital were reviewed. All patients who required re-exploration showed no significant difference between the two groups (LGB within the first 60 days post-op were considered. group:64.65 ±19.67 vs OGB group:59.68 ± 19.01, p=0.28). Results:Five patients underwent six laparoscopic explo- Conclusion:Laparoscopic Roux-Y bypass is a technically rations.Mean BMI was 51.Patient one underwent revision for feasible and safe operation which is becoming more popular.In proximal anastomotic obstruction at 58 days post-op. Patient this case-controlled comparison the initial results in weight loss two, lysis of adhesions for obstruction 7 days post-op. Patient are identical, thus confirming the efficacy of LGB. three underwent exploration on post-op day two without findings and proved to have an anastomotic stricture.Patient four was 32.RETROSPECTIVE COMPARISON OF LAPAROSCOPIC explored on post-op day two for revision of the distal anastomo- VERSUS OPEN GASTRIC BYPASS FOR MORBID OBESITY. sis and again four months post-op for reduction of an internal Anna Uskova, MD, George Bentzel, MD, Devora Hathaway hernia.Patient five developed obstruction at the level of the BSN, Daniel Gagne MD, Raye Budway MD, Robert Quinlan MD, transverse mesocolon secondary to cicatrix and required Phillip Caushaj MD. Dept.of Surgery, Temple University School laparoscopic lysis.Four patients recovered without further com- of Medicine clinical campus at The Western P ennsylvania plications and one patient required endoscopic dilatations of the Hospital,Pittsburgh, Pa.USA proximal anastomosis. Background:Laparoscopic Roux-en-Y gastric bypass (GBP) Conclusions :In the course of treating morbid obesity with is technically possible, and prior studies reflect comparable laparoscopic intervention complications will arise.Laparoscopic complication rates and outcome with fewer wound problems exploration for early complications is a safe and feasible option. than open GBP.In this review, we evaluate our experience at Western Pennsylvania Hospital (WPH) with both techniques to 34.THE ART OF RECYCLING: LAPAROSCOPIC VENTRAL determine safety, efficacy and outcome. HERNIA REPAIR AFTER OPEN ROUX-EN-Y GASTRIC Methods:Data, including demographic, perioperative, and BYPASS. outcome was retrospectively collected on all patients who Marina S. Kurian, MD , Daniel Marcus, MD and Mitchell S. underwent GBP at WPH from Oct 1997 to March 2001. This Roslin, MD. Department of Surgery , Lenox Hill Hospital, New consisted of 103 patients;58 laparoscopic, and 45 open cases. York, NY All data was compared between the two groups of patients Background:Open gastric bypass has been shown to have a based on laparoscopic versus open technique, statistical analy- ventral or incisional hernia rate of 12-30%. In the past, these sis was performed on all appropriate data, and trends were have been repaired using an open technique. We present a evaluated. series of laparoscopic ventral hernia repairs performed on our Results:Both groups displayed similar demographics, includ- patients that underwent previous open gastric bypass surgery. ing:age (mean 43), sex (female:male ratio 4:1), preoperative Methods:Prospective collection of data was performed in six BMI (laparoscopic group 49.35, open group 53.35 (p = 0.059)). patients that underwent laparoscopic ventral hernia repair after Mean operative time was significantly less in open GBP group previous open gastric bypass.Three trocars were used for lysis (p<0.005), as well as time under anesthesi a (p<0.005). of adhesions.An additional trocar was used to facilitate place-

384 Obesity Surgery,11, 2001 Crete Abstracts ment of the mesh. SURGERY. Results:All six procedures were completed laparoscopically. János Bende,Mikló s Ursu,Mikló s Csiszá r. Péterfy Hospital Mean pre-bypass BMI was 53.1 and BMI at the time of hernia Budapest Department of Surgery, Budapest, Hungary repair was 33.8.The mean time interval from bypass surgery to Background:The first steps in laparoscopic surgery treating hernia repair was 16 months.Mean operative time was 192 min- morbid obese patients in Hungary were in the year 1999.Our utes and mean hospital stay was 1.3 days.Mean size of the her- department decided to use this method the same year, since nia defect was 170 cm2 and the size of mesh used was 395 treating these patients in our country conduct the same prob- cm2.3/ 6 patients had a recurrent ventral hernia and 2 of these lems as elsewhere n Europe.With its minimal invasiveness, patients had prior open mesh repair.1/ 6 patients had a hernia reversibility and adjustability it seems the right choice in surgery, at a site other than the incision for the open bypass procedure. results are reported good.We perform our early experiences. There were no mortalities, and one patient had a suture granu- Methods:Between May 1999 and March 2001 27 patients loma removed ten weeks postoperatively.Mean follow-up period underwent laparoscopic adjustable gastric banding procedure after hernia repair is 2.5 months and there are no recurrences. in our department.22 men,5 women, the mean age was 47/34- Conclusions :Laparoscopic ventral hernia repair after open 57/46/40-52.Out of the27 operations 17 was LAGB and 10 was gastric bypass surgery is feasible and can be safely performed with the Swedish Band. in patients with good short-term results. Results:Our mean operating time was 97 minutes / 78- 172/,there was no mortality.One reoperation occurred because 35.LAPAROSCOPIC VENTRAL HERNIA REPAIR IN of gastric perforation, otherwise no converting was needed.The MORBIDLY OBESE AFTER OPEN ROUX-EN-Y GASTRIC follow–up showed 36 kg mean weight loss, BMI changing to BYPASS. 39.7 kg/m2 Piotr J Gorecki, MD, LD George Angus, MD. Nassau University Late postoperative complication was 2 port site inflammation, Medical Center, East Meadow, NY had to be treated surgically. Three cases of laparoscopic repair of a large ventral hernia Conclusion:We are looking forward for good and better after obesity surgery are shown.The technique is described and results treating morbid obese patients with adjustable gastric the results are presented. banding via laparoscopic technique. Conclusion:Laparoscopic ventral hernia repair may be a preferred option for the repair of a large ventral hernia in the mor- 38.BAND EROSION AND SLIPPAGE: DETECTING AND bidly obese.This group of patients may particularly benefit from AVOIDING LONG-TERM COMPLICATIONS. decreased incidence of wound complications, shorten recovery J.A. Lopez Corvala, F .Cordero Guzman, A. A.A.Ortiz and reduced recurrence rates. Lagardere. Laparoscopic Group of Baja California, OBCT Control Center, Tijuana, Mexico. 36.LAP AROSCOPIC ADJUSTABLE GASTRIC BANDING IN Background:A main concern with LASGB is Band Slippage HIGHLY OBESE. and Erosion.We present our experience with the complication F.Aigner, MD, H.Weiss, MD, H.Nehoda, MD, H.Bonatti, MD. and our treatment method. Univ.Hospital of Surgery, Dep. of Gen.Surg., Innsbruck, Austria Patients and Methods :A total of 200 Lap-Band procedures Background:From Jannuary1996 to April 2001 we implan- were performed from September 1996 to December of 2000. tated 401adjust able gastric bands to 381patien ts Distribution by sex is as follows:Female 73% Male 27%, Age (5female:1male, BMI 35-61, mean45). 32, (14-62), weight 138kgs (90-222);BMI: 46kg/ m 2 (35-78).The Method:We used a subcardial implantation technique form- first 18 procedures in our series were performed with the peri- ing a small funduspouch The first 3 cases we did by laparotomy gastric technique and a 25 cc proximal pouch.The rest of the then we changed to laparoscopic technique and had to convert procedures were done with the Pars Flacida and the Mexican in 3 out of the next 7 cases.After this learning curve convertion Technique and a virtual or 15cc proximal pouch.Complications was necessary only 7 times.Mean operationtime was 110min are described as trans-operative, and early and late postopera- (65-230min), mean hospitalisation p.o.3 days. tive. Results:385 times we used the Swedish band (Obtech com- Results:After a four-year experience with Adjustable Silicone pany/Switzerland), 16 times the Lap-Band ( Bioenterics comp./ Gastric Banding we have experienced complications during and USA ).Half of the Lap-bands we had to remove due to stoma- after the procedure.We had only one trans-operative complica- narrowing, 6 of them we substituted by a Swedish band. This tion (0.5%) a hemorrhage from a lacerated spleen that did not stoma narrowing might have been the consequense of our tech- require splenectomy .Early postoperative complications were nique to keep all the fatty tissue around the stomach inside the encountered in two cases (1%) A large access port hematoma band to prevent wall-injuries.Therefore the diameter of the Lap- that required drainage, but subsequently had an abscess for- band was to small especially in more obese patients. mation and ultimately needed port removal. The second case Patients with BMI<45 needed in the mean 12 month to reach a had a total stoma obstruction that required a 5-day hospital stay BMI<30, when BMI was >50 then 24 month..In 5% we had gen- with NPO until gastric edema subsided.No revision or removal eral, in 1,5% intraopeative and in 14% late complications, but of the band was necessary.Late complications were related to only in 12 cases they lead to bandloss and so to a failure of the Access ports site infection, recurring infection, abscess forma- method (3%). One patient died due to pulmonal embolism 2 tion and chronic fistula in 22 patients (11%) All patients had month postoperatively. aggressive antibiotic therapy , abscess drainage and port Conclusion:Adjustable gastric banding is an easy minimally removal if needed. Eight patients developed a chronic fistula invasive method to treat obesity, with a regular weigthreduction and four had recurring infection. All patients were scoped for and is well accepted by the patients. suspicion of band erosion. Late complications related to the band were slippage and erosion. Band slippage presented in 37.OUR INITIAL STEPS IN LAP AROSCOPIC BARIATRIC two patients (1%) The first patient, a 45kg/m 2 BMI female had

Obesity Surgery,11, 2001 385 Crete Abstracts total oral intake intolerance 12 months after surgery .Barium group sessions.Groups are maximum 12 patients and consist swallow demonstrated a band in a low position and a proximal of patients with a BIB™ System placed since a few weeks, gastric pouch.Band deflation was necessary and liquid diet was patients with a balloon placed for a few months and patients indicated.T wo months after, recurrence of symptoms and total who have the BIB™System removed, after a six month period. obstruction, required a laparoscopic band removal.Her BMI is Furthermore the patients have the possibility to have personal 34kg/m2 more than a year after her band removal.The second coaching with a NLP trainer. patient a 54kg/ m 2 BMI Female, 12 months after surgery presented a violent vomiting episode during a GI infection.T otal 40.5-YEAR RESULTS OF LAPAROSCOPIC GASTRIC obstruction developed and again a barium swallow demon- BANDING FOR MORBID OBESITY. strated a slipped band and total stoma obstruction with a large M.K.Müller1; M.Weber1; O.Schöb2;L.Krähenbü hl 1;R.Schlumpf 3; proximal eccentric pouch.Laparoscopic band removal was indi- R. Hauser4. 1UniversityHospital Zürich; Visceral Surgery, Zürich, cated.Her actual BMI four months after her band removal is 2Spital Limmattal;Visceral Surgery, Schlieren, 3Kantonsspital 31kg/m2.We have encountered eight band erosions (4%) Only Aarau, Department of Surgery, Aarau, 4Consultant for Nutrition, one was asymptomatic and detected during an endoscopy after Zürich; Switzerland upper GI bleeding from a duodenal ulcer.The other seven pre- Background:We present our 5-year results with the lapro- sented as recurring port site infection, chronic fistula or loss of scopic gastric banding (LAP-Band ®).The presented study early satiety.All presented during the first sixteen months after analyses the effect of the gastric banding with special regards initial surgery.Two bands have been removed laparoscopically. to metabolic changes and perioperative morbidity (infection, Indication for removal was total penetration into the stomach slippage, pouch-dilatation). lumen and chronic fistula with no response to antibiotic therapy. Methods:Between May 1995 and July 2000 the data of 161 Seven of the eight bands have eroded partially (less than 50% laparoscopic implanted gastric banding have been assessed of the band penetrating) and have either the outside or lower prospectively.The preoperative evaluation included besides the edge penetrating the stomach into the anterior fundoplication. history and a clinical status with anthropometry, an impedance- None have erosion of the buckle or tubing. All patients have analysis, an indirect calorimetry, blood testing, an ultrasound of video-graphic evidence of a floppy anterior fundoplication and the abdomen, a gastroscopy, a manometry of the esophagus pinching of the stomach was ruled out.Three of the band ero- and a contrast radiography of the esophagus and the stomach. sions had no previous band inflation or adjustment. Results:The mean body-mass-index (BMI) before implanta- Conclusion:LASGB has a low complication rate and in our tion was 48 kg/m 2 (range 34-71);within 3 years the mean BMI series has no mortality.Band slippage is minimal and has dimin- was 37 kg/ m 2 (range 24-55). The mean fat-mass went down ished with the higher positioning of the band.Low positioning of from 61 kg to 42 kg, whereas the body-cell-mass changed from the band and violent vomiting have been related to band slip- 40.6 kg to 30 kg.The excessive weight loss after 36 months was page.Band erosion is un-frequent but should be suspected 42%, the fat-mass-loss was 25%.All gastric bandings could be when recurrent port infection or fistula are present and should implanted laparoscopically with a conversion rate of 0%. In a be ruled out when the patient has loss of early satiety .All collective of 149 patients with a follow-up of 5 years, we had to LASGB patients should undergo routine endoscopy 18 to 24 perform a rebanding due pouch-dilatation in 20 cases (13.4%). months after initial surgery.In partial band erosion, removal is This procedure could be done laparoscopically in 19 cases.The indicated only when a band has lost its restrictive mechanism or perioperative mortality for first and second interventions was 0% symptoms are recurrent or uncontrollable with non-surgical in our series. measures.Port site complication is frequent and can be treated Conclusions :The laparoscopic implantation of a gastric with aggressive antibiotic therapy and will occasionally need banding leads to a successful and on holding reduction of the port removal for chronic infection or sinus tract.All in all, laparo- body weight with a very small perioperative morbidity and mor- scopic adjustable silicone gastric banding has a good and sus- tality.In the longterm follow-up one has to deal with more sec- tained weight loss at four years, no mortality, and a re-operation ondary interventions due to pouchdilatation, which can be rate of 1.5% in our series. managed laparoscopically as well.

39.USE OF BIOENTERICS INTRAGASTRIC BALLOON 41.SWEDISH ADJUSTABLE GASTRIC BAND–REOPERA- SYSTEM FOR OBESITY TREATMENT. TION AND EROSION. L.J.D.M.Schelfhout MD, PHD. J.Scherpenisse Medical Centre Antelmo Sasso Fin. Hospital São Luiz Rotterdam Airport D .Gabriels-Verweyen Body Services. The show how to take the band out and show how to put Medical Centre Rotterdam Airport, The Netherlands again when the patient has erosion.First step we start the oper- The BioEnterics Intragastric Balloon (BIB™ System) was ation at the same point in the first operation by laparoscopic introduced in a multi disciplinary group treatment for patients way, by shot dissection even localize the band capsule infected, with BMI between 30 and 40. is recommended the use antibiotic 7 days before the operation. Since June 2000 we have treated 400 patients and have a So the capsule is open, the locker is identify and open too, the one-year follow –up on 35 patients.Standard technique is gas- band is pulled, the hole is closed, we use always drain. troscopy and BIB™ System placement under sedation. Direct One to three months after, we perform a new operation to put after placement, the patient is send home.Patients are advised a new band, by laparoscopic way , by shot dissection, even to to drink at least 2 litres water per day.The first days after place- obtain a safe anatomy.The goldfinger will be better placed if you ment the patients routinely are too sick to eat. This problem put it below the lowest point of the right diaphragmatic pillar and solves in 98% of the cases, after a maximum of 5 days.BIB™ above the left gastric artery tunneling carefully through the old System’s are removed in the majority of patients after 6 months. fibrosis tissue behind the retoperitoneal part of stomach coming The follow-up is organized to start the first week after placement through the gasrtrophrenic ligament, sometimes it is difficult and is a full year program. Patients have dietary advises and prenetrate.

386 Obesity Surgery,11, 2001 Crete Abstracts

The operator should choose the location must convenient for Centre (private practice), Lyon, France. close the band, taking care because now the stomach wall is Background:One of the bigest problem of the gastric band- double;remembering that later the entire anterior transverse ing is slippage of the band that we can see in more than 10% of diameter of the stomach must be used to establish the tunnel the case and that the wall should only approximate the band loosely Methods:We present an alternative technique to facilitate allowing only enough space to accommodate inflation of the band placement without retrogastric tunneling and a new band band without traction on the stomach covering the band. HELIOGAST.Instead of creating the retrogastric tunnel, the sur- We conclude that erosion of the stomach wall becomes the pro- geon incises the gastrohepatic ligament at its transparent mem- cedure a little bit difficult but not impossible and we can solve brane and the first assistant retracts the lesser curvature tissues the problem to these patients. laterally and upward. By using blunt dissection the surgeon exposes the crural decussation away from the posterior gastric 42.LAP-BAND AND HIATUS HERNIA. wall and omental bursa and carries the blunt dissection forward Francesco Furbetta, G.Gambinotti. Ospedale di Pescia, Pescia, the angle of His.A grasper is pulling the Heliogast band and is PT positionned under a small gastric pouch.We use this technique Background.Epidemiological and endoscopic studies show with the Heliogast band in 130 patients that the incidence of gastroeso phageal reflux disease Results:So far we have performed 130 procedures using this (G.E.R.D.) and hiatus hernia (H.H.) are 4-11% and 6-9%, two steps technique and this Band.Operating time is now 25 to respectively.Furthermore, 32-42% of patients with G.E.R.D . 60 minutes;There were no deaths, no gastric perforation, and present a H.H., while 20-23% of those with H.H. also have no band erosion.On a mean follow up of 6 month there where G.E.R.D.;pathological obesity contributes to the increase in no patients with band slippage.Postoperative contrast studies these conditions.Although a consensus has not yet emerged as reveal identical band position as with the traditional retro-gastric to the effects on G.E.R.D .of gastric banding operations for tunnel technique. Weight loss matches to what has been pathological obesity, nor are there endoscop ic and described for the retro-gastric technique. pHmanometric data, it is clear that there is a technical problem Conclusion:This technique provides a good alternative to the as to the indication for banding, since a H.H. could cause usual retrogastric tunnel dissection.We believe that limiting the upward migration of the stomach into the thorax.The aim of this posterior dissection and using this circular band is important in study is to show that laparoscopic positioning of the Lap-Band preventing slippage. Our previous experience is in more than system (BioEnterics) may be executed concurrently with treat- 500 gastric banding with the Lap-band and the SAGB with a ment for H.H. and/or G.E.R.D. in adherence to the technical rate of slippage of 5% for first 100 cases.The first results with principles of the appropriate procedures and with a theoretical this combined technique are encouraging us to continue with increase in the resistance of the gastric pouch to dilation-herni- more follow up. ation. Methods:Between October 1995 and April 2001 495 patients 44.SWEDISH ADJUSTABLE GASTRIC BANDING IN were treated with lap-band (135 males and 360 females) with a MORBIDLY OBESE: THREE YEARS EXPERIENCE. mean age of 43 years (range 19-75) and a mean B.M.I.of 42.6 Hany Aly Nowara, MD , FRCS. Cairo University Hospital & (range 33-65);all operations were begun and completed laparo- Mokattam Surgery Center scopically in absence of intraoperative complications and mor- Background:Surgery has been recognized as an effective tality;19 patients showed a H.H., either with or without long term treatment for morbid obesity .The purpose of this G.E.R.D., of such dimensions as to interfere with correct posi- study is to present an Egyptian experience using the Swedish tioning of the Lap-Band.In the first group (13 patients) we per- Adjustable gastric band (SAGB) in cases of morbid obesity after formed a posterior cruroplasty together with the Lap-Banding passing the learning curve. operation, and in the second a posterior cruroplasty and fundo- Methods:202 morbidly obese patients having a body mass plication (3 Toupet, 2 Nissen, 1 Dor). index (BMI) >40 kg/m 2 were included in this study.The proce- Results and Conclusion :In all cases, it proved possible to dure was performed through a 4 or 5 trocar technique. The proceed with a rational and simultaneous treatment of the Swedish adjustable gastric band was used in all cases.The port pathologies in question with no complications, In our experi- was placed in the presternal position in most of the cases.Filling ence, H.H. and G.E.R.D.are not counter-indications for the Lap- of the balloon was attempted one month after the surgery. Band operation, which can be combined with treatment for Results:The mean age of the patients was 36.2 years.The these pathologies in adherence to the technical principles mean BMI was 56.2 Kg/ m 2.The mean hospital stay was 2.3 underlying the surgical procedures. Fundoplication reinforces days.The mean BMI after 12 months was 35.2 kg/m 2 & after 24 the gastric pouch and eliminates mobility of the fornix of the months was 33.4 kg/ m 2.Port complications were noted in 6 stomach, reducing the risk of herniation-dilation of the pouch.At patients, in the form of infection in 5 patients & bleeding in one present, a large H.H. requires hernia repair for correct position- patient.Liver injury occurred in 2 patients & pleural injury in one ing and duration of the Lap-Band in the abdomen, while patient.Primary band intolerance was seen in one patient & the G.E.R.D.may be treated with a conventional fundoplication, band was removed laparoscopically.There was no gastric per- although controlled studies are required to assess the functional foration nor erosions nor slippage in this series. outcome of fundoplication in the presence of a Lap-Band. Conclusions :laparoscopic insertion of the adjustable gastric band proved to be a safe and effective method for the treatment 43.PRELIMINARY RESUL TS AFTER COMBINA TION OF of morbid obesity in Egyptian patients provided that the surgical USING THE HELIOGAST BAND AND THE TWO STEP TECH- team had a previous learning curve. NIQUE TO PREVENT COMPLICA TIONS OF THE LAP ARO- SCOPIC GASTRIC BANDING. 45.LAP AROSCOPIC VERTICAL BANDED GASTRO- Salomon Benchetrit, MD . Chirurgie Generale et Digestive PLASTY AND ROUX-EN-Y GASTRIC BYPASS: TWO YEARS

Obesity Surgery,11, 2001 387 Crete Abstracts

EXPERIENCE. ratio was only significantly correlated with regurgitation (0.515, Cruz F, Cruz JL, Canga J, Gómez P, Martínez JI, Menéndez JM, p=0.003) and vomiting in the night-time (0.333, p=0.03).These Yuste P , Villarejo P , Pé rez E, Moradiellos J. 12 de Octubre symptoms disappeared after reduction of volume of the band. University Hospital (Madrid).Leó n Hospital (León). The amount of ml filling of the band and decrease of BMI dur- Background:The use of the laparoscopic approach to per- ing follow up showed no correlation with the O/B-ratio. form bariatric operations of proven efficacy seems to offer great Conclusion:Moderate oesophageal dilation, related with advantages to the morbidly obese patients.Our objective is to symptoms in the night-time, was observed in a significant pro- evaluate the feasibility of a different laparoscopic gastric bypass portion of the patients during follow up after LASGB.The dila- operation. tion is fully reversible, by decreasing the volume of the band with Methods:Since June 1999 to May 2001, 51 patients have disappearance of symptoms, and seems therefore of little clini- been operated on by the same surgical team.Mean age was cal relevance. 38,5 years.Weight 129.1 kg.BMI 47.5.Excess weight 103.8%. Eight had cholelithiasis.Three have been cholecystectomized, 47.RE-OPERA TIONS FOLLOWING LASGB. another three have suffered gynecologic operations and one a Ralph Peterli, Andrea Donadini. Peter Tondelli Surgical Clinic, umbilical herniorraphy .A laparoscopic vertical banded gastro- St.Claraspital Basel, Switzerland plasty and gastric bypass was performed to all the patients, Background:Re-operations after laparoscopic adjustable associated to a cholecystectomy in the eight cases referred. gastric banding operation (LASGB) are either band associated Results:Mean operation time has been 3:58 h.One patient or due to complications of the access port.Symptoms, diagnos- (2%) was converted to open because a methylene blue leak at tics, operations and follow-up of patients with re-operations the end of the operation. Mortality 1 (2%). Morbidity: 2 anast- were analyzed. motic leaks, 2 upper digestive bleedings, one intraabdominal Methods:Between 12/1996 and 4/2001 210 morbidly obese bleeding, one nasogastric tube entrapment, one wound infec- patients were treated with LASGB and prospectively evaluated tion and one urinary infection.The % excess weight loss at 12 using a standard protocol. Since 6/ 00 the pars flaccida tech- months has bee 77 %.The mean hospital stay 3,7 days. nique was applied, since 10/00 with the new 11cm LAPBAND®. Conclusion.Our two years experience shows that this tech- All adjustments of the band were done under radiological con- nique of laparoscopic vertical banded gastroplasty and gastric trol. bypass is feasible, safe and it seems that efficacious, although Results:35/210 patients had to be re-operated due to band it needs great expertise on laparoscopic and bariatric surgery. associated complications:2x laparoscopic removal of the band (1x due to pain, 1x pouch dilatation);21x laparoscopic re-gas- 46.ESOPHAGEAL DILATION AFTER LAP AROSCOPIC tric banding after 13 (3-26) months due to slippage or pouch ADJUSTABLE GASTRIC BANDING: MYTH OR REALITY? dilatation;10x BPD “duodenal switch”after 26 (18-39) months Justin R de Jong*, Cas HJ Tiethof**, Robin Timmer***, Andre due to pouch and/or esophageal motility disorders (7x) or insuf- JPM Smout****, Bert van Ramshorst*. Depts.of Surgery*, ficient weight loss (3x), in 5 cases after having already per- Radiology** and Gastroenterology***, St Antonius Hospital formed a re-banding for slippage.6 revisions of the access port Nieuwegein Dept.of Gastroenterology**** University Medical were done after 13 (2-27) months due to disconnection of the Centre Utrecht, The Netherlands tube at the port (3x) or dislocation of the port (3x).For patients Background:Oesophageal dilation is an unknown and not with a minimal follow-up of one year the re-operation rate fully examined complication following laparoscopic adjustable dropped from initially 38% to 14% with an average of 20%.The gastric banding (LASGB). early morbidity of the reoperations were:1 haematoma in the Methods:Forty-five patients who underwent a LASGB proce- abdominal wall after re-banding and 1 pulmonary embolism fol- dure between November 1995 and August 1999 were assessed lowing BPD, no deaths.After re-banding 13/21 had an unevent- for the presence of oesophageal dilation. The patients were ful course but 38% had an insufficient band function.No slip- analysed by repeated standardised barium swallow studies page occurred with patients operated with the new technique. immediate postoperatively and after a median postoperative fol- Conclusion:Re-operations after LASGB for band associated low up of 40 months (19-64). For each examination a ratio complications remain a frequent problem in spite of a learning between the maximum oesophagus diameter and band diame- curve but can be performed safely with little morbidity.Changing ter was calculated.Symptoms at follow up were assessed by a the operative technique and with the use of the new 11cm LAP- standardised questionnaire concerning questions about heart- BAND® the high slippage rate will be reduced. burn, regurgitation, nausea, vomiting , dysphagia, satiety and belching. 48.EVALUA TION OF 150 PATIENTS WITH LAPAROSCOPIC Results:An overall significant increase in the mean oesoph- ADJUSTABLE GASTRIC BANDING. agus/band ratio (O/B-ratio) was found comparing the immediate Casalnuovo Carlos Alberto, Ochoa de Eguileor Ezequiel, Rozas postoperative and long term series (0.52 (SEM 0.02) vs.0.72 Horacio, Panzitta Marí a. Hospital de Clí nicas, University of (SEM 0.03);p<0.01). In 19.4% a decrease, and in 80.6% of the Buenos Aires, and Private Practice (CCO-Centro de Cirugía de patients an increase of O/B-ratio was observed.In 51.7% of the la Obesidad), Buenos Aires, Argentina. patients with increase the ratio was between 1 and 1.5, in 6.8% Background:The adjustable gastric banding system (Lap the ratio exceeded 2. A significant correlation between the Band) is established as a reliable, simple, safe and minimally increase of O/ B-ratio with duration of follow up time (0.389, invasive placement for surgical treatment of morbid and super- p=0.02) and severe delay of oesophageal clearance of barium obese patients. (0.475, p=0.003) was found.Reduction of the band volume in 5 Material and Methods :The First Bariatric Surgical Program patients with severe delay of oesophageal clearance, resulted in began in Argentina in 1988 with non adjustable gastric banding, normalisation of the O/ B ratio (mean oesophagus/ band ratio using laparoscopic approach from 1994 and the laparoscopic 1.6(SEM 0.1) vs.1.1(SEM 0.1);p=0.002). The increase of O/B- adjustable gastric band (Lap-Band) from 1998. In the period

388 Obesity Surgery,11, 2001 Crete Abstracts

January 1998 - January 2001, 150 morbid obeses (MO) and in all these cases.In the 121 first cases, the proximal pouch was superobeses (SO) patients were operated on, with 74 % female, calibrated with 25 cc of saline.All the others were calibrated with mean age 42 years (16-60), mean weight 143 kg.(93-280), 81.1 15 cc.The mean operative time was 60 minutes (range: 20 – kg.(34-208) of excess weight and a percentage of ideal weight 180).In 6 cases (1.15%), a conversion to laparotomy was nec- of 231.1%.The initial BMI mean was 52.8 (35-89.3), 56% had a essary (1 left liver hypertrophy, 1 wrong position of trocart , 4 BMI = /> 50 (superobeses, supersuperobeses and triple obe- severe adhesions due to previous VBG).The mean hospitalisa- ses) and 12% = /> 66 (triple obesity).Comorbidities: AHT 63%, tion stay was 1.3 days (range 0 – 7).Specific intraoperative Dyslipidemia 58%, Osteoarth ritis 53%, OHS/ SAS 43%, complications were gastric perforation (1 case) and bowel per- Diabetes II 34%, Hiatal hernia 22%, Hyperuricemia 25%, foration (1 case). These were diagnosed peropertively and Cholelitiasis 25%, and Cardiovascular diseases 13%. treated by suturing.A short vessel hemorrhage needed a dis- The original perigastric technique was used in the first 30 section of the great curvature in order to perform a safe control. patients with “gastrostenometer”(electronic sensor).We modi- In 5 cases, liver dilacerations were observed and treated by fied the technique in the last 120 patients being able to: a) spray electrocoagulation.Deep veinous thrombosis occured in decrease surgical time, b) avoid complications, c) obtain a one case and basal pneunopathy in 2 cases.The most common higher and stable band position, d) create a virtual pouch at the late complication was total and irreversible food intolerance due beginning with a very small size later (15-20 cc).As associates to proximal pouch dilatation, whivh occured in 24 patients (4.6 procedures have been done 3 cholecystectomies (2%) and 10 %).Twenty of these cases had previously been calibrated with hiatal hernia repair (6.7%). 25 cc and 4 cases with 15 cc.The laparoscopic treatment (in all Results:The operative time in the last 140 patients was 75 cases) was the removal of the band in 6 cases, the reduction of min.(40-120), and 4 patients were converted to laparotomy the dilatation through a closed band in one case and the unlock- among the first 20 cases.There was no mortality, and the most ing of the band and its repositioning in 17 cases. In 2 cases important complications were the late ones, 2 slippages, 4 port- (0.4%), the band had to be removed due to psychological intol- infections, 1 hemoperitoneum, 1 balloon band leakage and 1 erance.Painfull gastric ulceration at the level of the band and gastric wall erosion.Through eight relaparoscopies (5.3%) have resistant to IPP required removal of the band in one case been treated the major complications, including 3 port infections (0.2%).In 5 cases (1%), band erosion with partial intragastric using a novel technique to place the tube-end far away in an migration appeared and was treated by laparoscopy with aseptic area. removal of the band and closure of the perforation.Connecting The mean follow-up was 18 months (3-36), with an excess tube disruption was observed in 15 cases (2.8%).In one other weight loss and BMI (pre 52.8) of 26 % and 47, 43% and 41, cases (0.2 %) port leakage was detected and a new port was 61% and 37, 67% and 32, and 67% and 32 at 3, 6, 12, 24 and placed under local anesthesia. Long term follow-up on 521 36 months respectively.The percentage of loss weight between patients (95.9 %) was obtained at 12, 24, 36, 48, 60, 86 months morbid and superobeses patients was similar. with a mean BMI respectively of 44, 33.2, 31.3, 30.1, 31.4, 31.2 A significant resolution of the registered associated illnesses, as and 32.1 kg/m 2.LASGB seems to be a safe procedure with a major and minor medical problems, were observed after weight low rate of complications.An acceptable rate of weight loss is loss.The incidence of arterial hypertension decrease 33%, obe- observed at long term . Most of the pouch dilatations can be sity hypoventilation syndrome 89%, diabetes 82.5% and gas- attributed to a 25 cc pouch calibration.Adhesions after VBG are troesophageal reflux 86%, with a global and important improve- the most important reason for conversion. ment in the quality of life. Conclusions :Although the results of this series appear 50.LAP-BAND, SAFE AND EFFECTIVE PROCEDURE: 4 encouraging, it is necessary a long-term follow up in order to YEAR FOLLOW-UP. establish reliable results.The implant of the adjustable gastric J.A.Lopez Corvala, F .Cordero Guzman, A. A.A.Ortiz band is an advance laparoscopic procedure and the good Lagardere. Laparoscopic Group of Baja California, OBCT results require a safe and standardized technique._The stoma Control Center, Tijuana, B.C., Mexico adjustment in the postoperative regulates in right form the Background:Adjustable Silicone Gastric Banding procedure weight loss with a reasonable tolerance to the food, being the for Morbid Obesity has had its share of bad reviews related to great advantage over other gastric restrictive procedures._The success rate and complications.We describe our results after a multidisciplinary approach with programs and special necessi- 4-year experience. ties is very important for the treatment of these patients. Methods:A total of 200 Lap-Band procedures were performed from September 1996 to December 2000. Distribution 49.LONG-TERM EXPERIENCE WITH LAP-BAND SYSTEM. by sex is as follows:Female 73% Male 27%, Age 32 (14-62), M.Vertruyen. Europe St-Michel Clinic, Brussels, Belgium Weight 138 kgs.(90-222); BMI: 46kg/ m 2 (35-78).Patient preop- Between october 93 and december 2000, 543 patients (487 erative work-up included Psychological and Nutritional evalua- females and 56 males) with a median age of 41 years (range : tion.All patients are approached laparoscopically.Barium swal- 18 – 65) underwent laparoscopic adjustable silicone gastric low is performed the morning after surgery and patients are dis- banding using the LAP-BAND ® System of Bioenteric s charged after 24 hours.We have weekly appointments the first Corporation.Twenty patients had a previous surgical history of eight weeks, and psychological and nutritional support is given vertical banded gastroplasty (VBG) with staple line disrup- then after every month for the first six months to a year.Band tion.All patients had been excessively overweight for more than adjustment is considered on the after the first eight to twelve 5 years.The mean body weight was 117 kg (range:95 – 251) weeks.Prior psychological and nutritional evaluation is neces- corresponding to a mean BMI of 44 kg/m 2 (range:35 – 67).On sary.After the first year counseling will vary according to each the 543 patients, follow-up was obtained in a period ranging patient. from 3 to 86 months (median follow-up : 36 months) in 521 Results:All of the procedures were completed laparoscopi- patients (95.9%).The perigastric dissection technique was used cally except two (1%).T echnical difficulty was related to exces-

Obesity Surgery,11, 2001 389 Crete Abstracts sive intra-abdominal fat (0.5%) or a very large fatty liver (0.5%). complication related to hematoma at the adjustment port site Total surgical time on average was 75 minutes (25-185). OR and late complications at the same level with port site infection, time was notably diminished after the first 100 cases where total recurrent infection, chronic fistula in 22 patients, (11%) Late time diminished to 50 minutes.Longer OR time over 90 minutes complications included slippage in two cases (1%) arising 12 were related to BMI larger than 55. The perigastric technique months after initial surgery.We have detected eight band ero- was performed in the first 18 patients;we then changed to the sions (4%); all have appearing in the first 12 months after pars-flacida and Mexican Technique.Excess body weight lost surgery.Laparoscopic band removal was indicated in two has been 64% (38-110%) and BMI averaged at 32 Kg/m 2 (22- cases.All band erosions were confirmed by upper endoscopy. 54).We have found a positive relationship between close multi- Conclusion:The laparoscopic adjustable silicone gastric disciplinary follow-up and weight loss. Forty-eight patients banding has proven its value over the years.It is a technically (24%) have never required a band adjustment, and after 18 straightforward procedure, with a moderate learning curve and months follow-up (12-36) have lost >50% EBW.The other 152 low in transoperatory and post-operative complication rate.It is patients (76%) have from 1-4 adjustments.All initial adjustments comparable in results to other mal-absorptive procedure with a require prior nutritional and psychological assessment. Only lower morbidity and mortality in our series.Band slippage is now one (0.5%) trans-operative complication was encountered, a minimal with the change in technique, and even though lacerated spleen which was controlled during the procedure presently band erosion appears in 4.0% of our patients, it is without the need of splenectomy.Hospital stay averaged 1.08 mandatory to perform a routine endoscopy after 24 months to days (1-5).Prolonged hospital stay was seen in two cases.The detect asymptomatic erosions.The overall benefits of LASGB first case a 77 BMI patient could not be removed from the ven- outweigh the risks by far.We conclude that good surgical team tilator.The second case a 55 BMI male had total stoma obstruc- and technique with a multi-disciplinary support group for long tion in the immediate postoperative period that resolved spon- term follow up will guarantee the success rate and diminish over taneously in the third day after surgery.One early postoperative all complication rate.

General Sessions

51.ASSESSMENT OF DIFFERENT BARIA TRIC OPERA- excess weight <50%), was achieved, at 4 y., in 72.7% of lap TIONS: DATA UP TO 5 YEARS FROM THE IT ALIAN REG- VBG, 37.1% of lap ASGB, 51.4% of open VBG, 74% of BPD; a ISTRY (R.I.C.O.). failure (residual excess weight >100%) was observed, at 4 y, in Mauro Toppino, MD;Michela Mineccia, MD;Silvio Gorrino, MD; 3% of lap VBG, 11.3% of lap ASGB, 5.7% of open VBG, 1% of *Roberta Siliquini, MD;Francesco Morino, MD; Registry BPD.Residual BMI was, at 4 years, 29.7 in lap VBG, 34.9 in lap Contributors. Department of Surgery, University of Turin, Italy - ASGB, 32.9 in open VBG, 29.8 in BPD. *Department of Public Health, University of Turin, Italy With regard to a morbid vs superobese comparison, a suc- Background:The RICO Registry started on January 1996 in cess was obtained in 79.2% of morbid and 55.6% of super- order to evaluate and compare long term results of different obese after lap VBG, in 38.3% of morbid and 33.3% of super- bariatric operations. obese after lap ASGB, in 53.6% of morbid and 42.9% of super- Methods:5073 interventions were recorded, from 40 Centers, obese after open VBG, in 75.3% of morbid and 69.6% of super- as follows:2015 VBG (39.7%), 1916 ASGB (37.8%), 950 BPD obese after BPD. (18.7%), 84 gastric by-pass (1.7%), 56 Bilio-Intestinal By-pass Reoperations occurred in 6.1% of cases, as follows:lap VBG (1.1%), 52 non adjustable gastric banding (1%).Open surgery 2%, lap ASGB 10.4% (in 6.3% for major complications, such as was performed in 50.2% of cases and laparoscopy in 49.8%. pouch dilatation, slipping stomach/band, erosions, and 4.1% for Among the 40 Centers, only gastric restrictive procedures were reservoir complications, such as leakage, twist, etc.), open VBG performed in 18 of them, only malabsorbitive operations in 4, 3.4%, BPD 3.2%, non adjustable bandings 34.6%. both restrictive and malabsorbitive in 13, restrictive procedures Conclusions :The RICO Registry allowed us to obtained data and gastric by pass in 5.Out of 2515 laparoscopic operations, on wide series and compare results between different opera- VBG was performed in 645 cases (25.6%), ASGB in 1786 tions evaluated with the same method.Even with a intermediate cases (71%), BPD in 55 cases (2.2%), Gastric by-pass in 29 follow-up, better results on weight loss were observed after BPD cases (1.1%), gastric banding in 9 cases (0.3%).The convertion (expecially with regard to preoperative BMI) and lap VBG too; rate was 6.6% in VBG, 2.8% in ASGB, 8.3% in BPD, 3.3% in lap ASGB showed the minor rate of early complications, but gastric by-pass.Average preoperative BMI was 45.3 Kg/m2 in results on weight loss were not so good and the reoperations open VBG, 44.6 in lap VBG, 44.4 in lap ASGB, 48.2 in BPD , rate was still remarkable. 51.4 in Gastric by-pass, 48.9 in bilio-intestinal by pass . Results:Operative mortality rate was 0.35% (0.25% in VBG, 52.VERTICAL BANDED GASTROPLASTY: RESULTS 10 0.21% in ASGB, 0.95% in BPD).Early complications occurred YEARS AFTER SURGERY. in 7.4% of lap VBG, 4.6% of lap ASGB, 9.9% of open VBG, Papavramidis Spiros, Kesisoglou Isaak, Apostolid is 10.1% of BPD.% Excess weight loss (EWL%) in lap VBG was Dimosthenis, Gamvros Orestis. 3rd Surg.Dept. AHEP A Hosp. 63 at 3 y, 60.4 at 4 y, 56.8 at 5 y.;EWL in lap ASGB was 42.6 at Aristotelian University of Thessaloniki, Greece. 3 y, 41.3 at 4y, 34.6 at 5 y.;EWL in open VBG was 54.1 at 3 y, Background:Vertical banded gastroplasty (VGB) and its mod- 56.5 at 4 y, 57.3 at 5 y;EWL in BPD was 65.3 at 3 y, 67.5 at 4 ifications represents a widely used operation for the last 15-20 y, 64.9 at 5 y, EWL in gastric by-pass was 57.9 at 3 y., 53.4 at 4 years.This method is preferred to the most complex operations, y., EWL in biliointestinal by-pass was 64.7 at 3 y. as it preserves the normal continuity of the alimentary tract and According to the Reinhold classification, a success (residual prevents complications that are common to other bariatric oper-

390 Obesity Surgery,11, 2001 Crete Abstracts ations. were collected.The patients recovery were registered by phys- Methods:Between January 1987 and December 1990, 48 iotherapist by measurements of lung function and hand-power patients with a BMI:53+22 kg/m 2 underwent VGB as a proce- as well as consumption of analgetics. dure of choice for the management of their disease. Patients Results:No patients were converted to open surgery. Five were followed-up by clinical, biochemical, hematological, upper GBP patients were re-operated;two had a laparoscopy because gastrointestinal barium meal and/or endoscopy. of suspected leakage, two had a laparotomy because of bleed- Results:Four of the patients died and additional 4 were lost ing where one was intraluminal.One had a laparotomy because during the follow up period.So, 40 patients had a complete fol- of a stenosis at the level of the entreoanastomosis.One GBP low-up, at least 10 years after surgery.Using Reinhold’s criteria, patient received blood transfusion postoperatively .After GBP the results were very good in 34% of the patients, good in 39%, also one deep infection. One VBG patient was re-operated moderate in 17% and poor in 10%.Six patients who regained laparoscopically because of a postoperative leakage and there- weight underwent a reoperation (two of them biliopancreatic after developed an abscess.T wo VBG patients received blood diversion and four vertical banded gastroplasty with artificial transfusion postoperatively .The postoperative recovery with pseudopylorus). respect to analgetic consumption, lung function and hand- Conclusions :Vertical banded gastroplasty is a safe, and a power showed only minor differences. The median in hospital long-term effective operation for severe obesity, producing sat- stay was 2-3 days in both groups. isfied weight loss ten years at least after surgery. Conclusion:Laparoscopic VBG as well as GBP can be carried out with low perioperative morbidity and short in hospital 53.LONGTERM RESULTS AFTER VBG AND LAP-BAND. stay.The number of re-operation in the GBP group was some- Husemann, B.Prof.M.D., TH. Sonnenberg Dominikus. what higher (5 vs.1) and the number of major complications Krankenhaus P.O.290151, D-40528 Dusseldorf/Germany were also somewhat higher (3 vs.1). As the operative risk in The analysis is based on a prospective clinical trial on 451 both groups is low we do not consider that it should be a domi- patients treated by VBG (82.4% female) and 127 patients with a nating factor in the choice of operation methods but instead the lap band (74.7% female).The minimum follow-up period of time long-term outcome with respect to weight development and is 24 months.The weight loss in both groups is comparable:The quality of eating. pre-op BMI is 49.2 ±7.0 for the VBG-group and 46,5 ±7.2 for the lap-band group.Weight loss is perfect in both groups with a 55.A RANDOMIZED PROSPECTIVE STUDY OF LAP-BAND BMI of 34.9 kg/m 2 (VGB) and 34.5 (lap-band) after 12 months VS VBG: AN INTERIM ANAL YSIS ON THE EFFECTS ON and 30.7 ±5,7 kg/m 2 (VBG) respectively 32 ±6 (lap-band) after QUALITY OF LIFE AND BMI. 24 months.After five years 46.2% and 43.4% reach a BMI under Francois van Dielen*, Ghislaine van Mastrigt**, Gemma Voss**, 30 kg/m2, even 20% below 25.As a consequence of the weight Jan-Willem Greve*. Dept.of General Surgery* and Clinical loss the patients improve their lab, especially the triglyceride, Epidemiology and Medical Technology Assessment**, cholesterol and blood glucose level are normalized. Physical University Hospital of Maastricht activity increases significantly .However there are important Background:The effects of medical interventions on quality of anatomical complications in the long term run: In the VBG- life are becoming more and more important. T o this end a group we have seen 19.3% suture line leats, 2.7% pouch dilata- prospective randomised trial to the effects of LapBand (LB) or tion and 8% stoma stenosis, in the lap band groups there are Vertical banded gastroplasty (VBG) on weight loss and quality 7.8% dislocations, 3.9% penetrations and 2.4% infection of the of life (Qol) was performed. port or the band. The re-operation rate reaches 17.7% (VBG) Methods:52 morbidly obese patients were randomised for LB and 10.2% (lap-band) after 60 month for bariatric surgery asso- or VBG. 23 patients (age 36.7 ± 7.4) underwent VBG and 29 ciated complications.The results for the weight loss are perfect patients (age 36.1 ±10.9) underwent a LB operation.BMI, qol for both groups, however the rate of reoperations due to (using Euroqol visual analogue scale (vas) and Dolan-algo- anatomical complications is high. rithm) and Nottingham Health Profile 1 (NHP 1) were measured preoperative (preop), as well as on 3, 6 and 12 months postop- 54.LAPAROSCOPIC VERTICAL BANDED GASTRO- erative (postop). PLASTY vs GASTRIC BYPASS – A RANDOMIZED CLINICAL Results:One year follow-up results are reported.BMI signifi- TRIAL. cantly decreased (P<0.01) from 47.2 ± 7.1 preop (n=23) to Torsten Olbers, Hans Lö nroth, Monika F-Olsé n, Lars Lundell. 38.1±6.0 kg/ m 2 at 3 months (n=23), 33.7 ± 4.7 at 6 months Department of Upper GI-Surgery , Sahlgrenska University (n=23) and 30.4 ±5.2 at 12 months (n=15) for the VBG group Hospital,Gothenburg, Sweden. and 46.2 ±5.3 (n=29) to 41.8 ±5.1 at 3 months (n=29), 38.9 ± Background:Many techniques are used today in obesity 5.4 at 6 months (n=29) and 34.6 ±6.3 at 12 months (n=22) for surgery.Up until now the restrictive procedures such as VBG the LB group.BMI preop did not differ between both operated and the adjustable band has been dominating numerously, at groups.However, 3 and 6 months postop BMI was significantly least in Europe.GBP has within the open surgery established decreased in the VBG group compared to the LB group (p=0.03 as “gold standard”as it combines excellent weight loss with few and p=0.004 respectively).At 12 months BMI did not differ.After eating disturbances.Laparoscopic techniques has been devel- VBG, Euroqol vas significantly (P<0.05) improved from 52.5 ± oped to perform all the mentioned operations.We hereby pre- 24.0 preop to 75.4 ±18.0 at 3 months, 78.1±16.7 and 78.5 ± sent the perioperative results from a randomised clinical trial 22.2 at 6 and 12 months respectively.After LB, Euroqol vas also between totally laparoscopically performed VBG and GBP oper- significantly increased (P<0.05) from 66.7 ±19.2 preop to 80.2 ations. ±10.9 at 3 months postop and 81.4 ±12.0 and 79.8 ±16.2 at Methods:During the period February 2000 to April 2001, 100 6 and 12 months postop respectively.Preop, Euroqol vas was patients with morbid obesity were, after full consent, ran- significantly different between VBG and LB group.After surgery, domised to VBG (n=51) and GBP (n=49).Perioperative data improvement of Euroqol vas was equal in both groups.Dolan-

Obesity Surgery,11, 2001 391 Crete Abstracts algorithm and the NHP 1 domains, except domain “pain”for the hospitals and the SOS secretariat, Göteborg 3 LB group and the domains “sleep”, “emotion”and “social isola- Background:The Swedish SOS study has survival benefit tion”for the VBG group, significantly (P<0.05) improved.No sig- from surgery as its primary end-point. There are several sec- nificant difference in incremental qol scores (for both Euroqol as ondary end-points.The power analysis was originally based on well as NHP 1) was found between VBG and LB group.BMI did an operative mortality of 0.5%; 10 years of follow-up on 2000 not correlate with quality of life. operated patients and 2000 obese control subjects should then Conclusion:In this interim analysis of a prospective ran- suffice for statistically significant conclusions to be reached on domised clinical trial, we demonstrated that at 3, 6 and 12 survival. months postoperative a significant improvement of quality of life Method:in the period Nov.1987 to Jan.2001 we performed after both LapBand and VBG was found.Despite a significant 2010 patients at altogether 26 participating surgical depart- difference in decrease of BMI 3 and 6 months postoperative, no ments.T wo special protocols (operation and hospital time resp.) statistical significant difference in quality of life improvement were filled out for all operated patients. This database was between the VBG and LapBand group was found. searched for demographic data, and for differences between procedures, techniques as well as between departments. 56.LAP AROSCOPIC ADJUSTABLE SILICONE GASTRIC Results:There were 1490 women, 520 men. Mean BMI at BANDING (LASGB) VS LAPAROSCOPIC VERTICAL operation was 41.3 for men and 42.8 for women.Antibiotic pro- BANDED GASTROPLASTY (LVBG):INTERMEDIATE phylaxis was used in 96%, thrombosis prophylaxis in 99%.The RESULTS OF A PROSPECTIVE, COMPARATIVE,MULTI- number of operations per department varied between 7 and CENTER TRIAL. 241.T en depts.performed <50 operations each, total 264.T en N Basso, F Favretti*, M Morino**,U Parini***, G. Silecchia, A depts.performed 51-100 operations each, total 707, and 6 Restuccia, U. Elmore, , M Toppino**. Dipartimento di chirurgia depts.performed >100 operations each, total 1039. The open “Paride Stefanini”- Policlinico “Umberto I” Università “La approach dominated (89.2%). VBG dominated as method Sapienza”Roma” , *Dipartimento Chirurgia Generale Osp S. (n=1368) followed by 377 gastric banding and 265 gastric Bortolo - Vicenza (ASL 6 V eneto), **Divisione Chirurgia - bypass operations.Mean operative time was longest for laparo- Università di Torino, ***U.O. Chirurgia Generale - Ospedale scopic gastric bypass (177 min.) and shortest for open gastric Regionale Valle d’Aosta banding (66 min.). There were no clear differences between Background:the adjustable gastric banding and vertical type of hospital and op.times. However, the trend was clear that banded gastroplasty represent the most widely used laparo- hospitals with the largest number of operations in this material scopic bariatric restrictive procedures. No prospective study also had shorter operative times, as well as hospital times.This comparing the two laparoscopic procedures is available. The latter finding was coupled to a more rapid return to oral alimen- aim of the present study was to compare two standard laparo- tation.The last 1000 patients in the series had on average one scopic procedures:LapVBG sec MacLean versus LASGB(Lap day shorter hospital time than the first 1000. Laparoscopic Band Bioenterics-McGhan ®), analyzing safety and efficacy at approach gave a shorter hosp.time (4.4 days) than open tech- 24 months follow-up. nique (7.6 days). Perioperative complications were 26 opera- Methods:design of the study:closed prospective multicenter tions with a blood loss >1000 ml, most commonly due to splenic (Turin-Aosta:L VBG; Rome-Vicenza:LASGB) comparative trial: damage necessitating splenectomy (n=16;0.8%). Reoperation 2 homogeneous groups (100 pts x arm).Inclusion criteria: frequency was 2.5%;higher for laparoscopic procedures (6%) A.S.B.S.criteria, age 18-65 yrs;BMI 40-50 (35-49 if comorbidi- than for open (2.1%). 222 patients (11.0%) had one or more ties).The follow-up data until 24 months p.o.were analyzed. complications prolonging hospital time with >24 hours; most Results:From June 1997 to Dec 1998, 233 pts (191 F, 42 M), commonly infectious and respiratory. mean age 37.8 (18-65) yrs, mean BMI 43.4 (36-50), were Conclusion:Operations for morbid obesity can be performed enrolled.Comorbidities were present in 61.4% of LASGB pts safely, and with short operative and hospital times. Increased and in 89% of LVBG pts respectively.The operative results for experience with this patient group and the operative methods LASGB (132 pts) and LVBG (101) were: mortality null in both seems to increase efficacy .The laparoscopic approach has groups;operative time 82.7 vs 93.5 minutes ;conversion rate more reoperations but a shorter hospital time.The value of obe- 1.5% vs nil;intra and post.op. morbidity 0.7% vs 7.8%;p.o. hos- sity surgery depends on the results on obesity and and its com- pital stay 2.2 vs 6.3 days.The drop at 24 months was 15%.The plications.Even small benefits are likely to justify surgery. reoperation rate, the BMI and %EWL at 24 months were respectively:6.8%, 33.6 and 42.5% in LASGB group; 1%, 29.6 and 58.BARIA TRIC SURGERY FOR THE SUPER OBESE : 63.2% in LVBG group.The comorbidities improved or resolved WHAT IS THE BEST OPERATION? in 73% (LASGB) and 77.4 % (LVBG). Joseph F .Capella, MD, Rafael F .Capella, MD. Hackensack Conclusions :Both laparoscopic procedures were safe.Early University Medical Center, Hackensack, New Jersey, USA. morbidity was higher in LVBG group (7.8 vs 0.7%).At 24 months Background:Proximal roux-en-Y gastric bypass has been follow-up:the LASGB group showed a higher reoperation rate reported to be ineffective in roducing weight loss in the super- (6.8% vs 1%);the EWL was significantly higher il LVBG group obese patient ( ³ 225% of ideal weight). Malabsorption proc- (63.2% vs 42.5); the results regarding the comorbiditie s dures have been recommended by several authors for this improvement or resolution were similar between the two groups. patients group.We studie d 247 individuals.Who underwent a compbination of vertical banded gastroplasty and roux-en-y 57.2010 OPERA TIONS FOR OBESITY IN THE SWEDISH gastric bypass (VBG-RGB). SOS STUDY: METHODS,HOSPIT AL TIME AND COMPLICA- Methods:The study involves 247 consecutive VBG-RGB’s on TIONS. 247 super-obese individuals.Data was obtained from 30 of the J. Hedenbro1, I. Näslund 2, G. Ågren2, A. K.Lindroos 3, L. 41 eligible patients at 5 years for a perchentage follow-up of 73. Sjöström3. Depts.of Surgery at Lund 1 and Örebro2 University The 30 patients had an initial BMI of 60± 8 and an average

392 Obesity Surgery,11, 2001 Crete Abstracts weight of 170 kilos (375lbs) REPORT. Results:At five year follow up the average BMI of the 30 MAL Fobi, MD, FACS. Center For Surgical Treatment Of patients was 32±6 with a percentage excess weight loss of Obesity, Tri-City Regional Medical Center, Hawaiian Gardens, 74%.Only two patients lost less than 50% of their excess weight USA (7%). Background:Prospective Evaluation of the Fobi-Pouch Conclusions :VBG-RGB has been effective in producing sat- Operation for Obesity. isfactory weight loss in superobese individuals at five years.We Method:The Fobi-Pouch Operation for Obesity is a gastric feel that VBG-RGB should be offered as a primary procedure for bypass with a banded, vertically transected 10-30cc estimated super-obese individuals.The few patients who fail to lose more pouch, with short Roux-en-Y Limbs.The efferent limb, used as than 50% of excess weight may be candidates for a malabsorp- a serosal patch to the cut edge of the pouch, is interposed tion procedure that can easily added to VBG-RGB. between the pouch and the bypassed Stomach. The gastro- enterostomy is distal to the band. A gastrostomy tube, and a 59.MALABSORPTIVE GASTRIC BYPASS IN P ATIENTS radio-opaque Marker at the gastrostomy site to facilitate access WITH SUPER OBESITY: COMPARATIVE STUDY OF ROUX to the bypassed segment, completes the Operation.All patients LIMB LENGTH. who had the primary Fobi Pouch Operation for Obesity at Robert E.Brolin MD, Lisa B.Lamarca MS, R.D.Ronald P.Cody, Cedars Sinai Medical Center in Los Angeles and at Bellwood EdD. St.Peter’s Univ Hospital and UMDNJ-RW Johnson Med General Hospital in Bellflower, California, from January 1st Sch,New Brunswick, NJ, USA through December 31st 1994, have been followed prospectively Super obesity has been defined as ³200 lb overweight or as to determine the outcome of this operation in the treatment of a BMI ³50 kg/m2.Weight loss results in super obese patients obesity. have been problematic after gastric restrictive operations includ- Results:Two hundred and seven patients had the Fobi-Pouch ing conventional short limb RY gastric bypass (RYGB). An ear- Operation as a primary operation in 1994.Nineteen men and lier report showed that a 150cm Roux limb produced signifi- 188 women were operated upon.The age range was from 16 to cantly greater weight loss vs.a 75cm Roux limb in super obese 74 years with a mean of 40 years.The BMI was from 34 to 78 patients.However, recidivism after 3 years was common in both with a mean of 47.3.The follow up rate at six years is 67%.Peri- groups.The goal of the present prospective study was to com- operative complications occurred in 18 patients (9%) with no pare weight loss using a distal RYGB (D-RY) in which the RY mortality.Late complications include 41 ventral incisional her- anastomosis was performed 75cm proximal to the ileocecal nias, 7 Cholelithiasis, 9 patients with excessive weight loss junction (N=47) vs super obese patients who had Roux limbs of and/or solid food intolerance, 6 small bowel obstruction, 5 with 150cm (N=152)and 50-75cm (N=99). All operations incorpo- gastro-gastric fistula, 4 band erosions, 3 gastro-jejunal fistula, 2 rated the same gastric restrictive parameters and were per- marginal ulcers and at this time an indeterminate number with formed by one surgeon.Minimum follow up period was 3 years calcium, iron and vitamins A, D, E, B-1, B-6 and B-12 deficien- and ranged to 16 years.Weight loss and reduction in BMI were cies.The average percentage excess weight loss at six years is significantly greater after D-RY vs.both RYGB-150, RYGB-75 67.2%, with a range of 29-113%. Most co-morbid conditions and in RYGB-150 vs.RYGB-75 through 5 years.Mean percent have been significantly ameliorated. excess weight loss peaked at 63% after DRY and RYGB-150 vs Conclusion:The Fobi–Pouch Operation for Obesity produces 55% after RYGB-75.Weight loss maintenance through 5 years excellent weight loss and maintenance with comparable accept- was correlated with Roux limb length with DRY >RYGB-150 able side effects in morbidly obese patients. >RYGB-75.More than 75% of obesity-related comorbidities improved or resolved with weight loss.There was no difference 61.EFFECTS OF LAPAROSCOPIC GASTRIC BANDING ON in early postop morbidity rate: 8.7% after D-RY; 8.5% after BODY COMPOSITION, METABOLIC PROFILE AND NUTRI- RYGB-150;2.0% after RYGB-75 with one death (0.3%) from TIONAL STATUS IN MORBID OBESITY: 12 MONTHS FOL- pulmonary embolism after RYGB-150.Diarrhea was noted in 17 LOW-UP. patients (36%) after D-RY; in one patient (0.3%) after RYGB- V. Giusti1, M. Suter2, E. Zysset1, E.Héraï ef 1, R.C.Gaillard 1, P. 150 and absent after RYGB-75.All D-RY patients had at least Burckhardt1. Department of internal medicine 1 and surgery 2, one postop metabolic abnormality.The incidence of anemia was University Hospital - CHUV, Lausanne, Switzerland significantly greater after D-RY vs.RYGB-150 and RYGB-75 (p Background:The significant weight loss which is usually < 0.05 D-RY vs.others). There was no difference in the inci- observed during the first 6-12 months after gastric banding is dence of metabolic sequelae between RYGB-150 and RYGB-75 due to an important reduction of food intake, with a potential risk patients.No operations were reversed or modified for nutritional of minerals and vitamins deficiency.The aim of this study is to complications.T wo D-RY patients required TPN for protein calo- evaluate the effects of gastric banding on total body composi- rie malnutrition.These results show that Roux limb length has a tion, nutritional status and metabolic profile. significant impact on weight loss in super obese patients. Methods:We studied 31 women with a median age of 36 However, it is unclear whether the superior weight loss and years who underwent laparoscopic gastric banding.T otal body weight loss maintenance after D-RY in comparison with RYGB- composition was measured before, 6 and 12 months after 150 is sufficient justification for its routine use in superobese laparoscopic gastric banding, using dual-energy x-ray absorp- patients having bariatric operations. We conclude that some tiometry (Hologic QDR 2000).Metabolic profile and nutritional degree of malabsorption should be incorporated in bariatric were evaluated before and 1, 3, 6, 9 and 12 months postopera- operations performed in super obese patients in order to tively. achieve satisfactory long term weight loss. Results:body composition WeightBMI FatFFM WaistHip EBW 60.PROSPECTIVE EVALUATION OF THE FOBI-POUCH (kg) (kg/m2)(kg)(kg) (cm) (cm) (%) OPERATION FOR OBESITY: A SIX-YEAR FOLLOW-UP Before119 43.7 64.7 50.2 115 138 207

Obesity Surgery,11, 2001 393 Crete Abstracts

6th month100 36.9 49.5 46.7 102 125 175 ence in postoperative weight loss between the two groups. (%loss) 1616 24 7 129 16 Results:The BAROS scores (maximum 3 points each) were (T-test p)<0.01<0.01 <0.01 <0.01 <0.01 <0.01 <0.01 “Weight loss % of excess”: 1.86 ±0.05 , “Comorbidities”: 1.70 ± 12th month91 33.5 40.9 45.4 95 116 159 0.07, “Quality of life”: 1.59 ±0.05.“ Complications”: -0.09 ±0.04; (%loss)23 23 37 10 18 16 23 total score 5.00 ± 0.12.23.1% of patients demonstrated an (T-test p) <0.01<0.01 <0.01 <0.01 <0.01 <0.01 <0.01 excellent result (score 7-9 points), 62.8% good (score 4-6 points) and 12.6% a fair result (score <0 points) .The failure rate metabolic and nutritional profile: was 1.5%.A major problem with the BAROS score is the under- Before1st 3rd 6th 9th 12th estimation of patients without comorbidities, affecting the young Glucose particularly, because they miss 3 points already at time of oper- (mmol/l)5.8 5.6 5.5 5.4 5.2 5.1 (p<0.05) ation (Patients with comorbidities (n=161): 5.30± 0.11 vs no Tot. Chol. comborbities (n=38):3.30± 0.21, p<0.001). (mmol/l)5.6 5.3 5.3 5.3 5.5 5.2 (p= n.s.) Conclusion:Gastric banding results in excellent weight loss, HDL Chol. improving quality of life with a low complication rate and signifi- (mmol/l)1.31 1.22 1.26 1.36 1.43 1.46 (p<0.05) cantly reducing the overall rate of comorbidities.More than 98% Triglycerides of patients demonstrated at least a fair result whilst more than (mmol/l)1.68 1.58 1.58 1.16 1.36 0.94 (p<0.05) 85% of patients showed a good or excellent result, using a team Urates approach comprising bariatric surgeon, obesity specialist, dietit- (mmol/l)327 338 319 296 280 275 (p<0.05) ian and psychologist. Tot.proteins (g/l) 76.7 76.5 77.7 76.1 75.6 75.6 (p=n.s.) 63.LAP AROSCOPIC GASTRIC BANDING: ONE SUR- Vitamin B12 GEON, 400 CASES, RESULTS AND COMPLICATIONS. (pmol/l) 217 252 236 217 214 221 (p=n.s.) Paul Anderson .Oarlunga Hospital and Ashford Obesity Clinic, Vitamin D3 Adelaide, South Australia (mg/l)19.4 18.3 17.4 20.3 22.0 20.4 (p=n.s.) Background:400 hundred cases operated on by one sur- Acid folic geon[ the author]are reviewed over a 4 year period. (nmol/l)23.3 21.1 19.5 17.8 17.4 19.3 (p=n.s.) Methods:The Lap Band (Bioenterics ) was inserted in Iron 378obese patients as a laparoscopic operation.The band was (mmol/l)14.0 13.4 13.7 15.4 14.9 16.1 (p=n.s.) inserted at the esophagogastric junction using the pars flaccida Ferritine approach.Of these 13 had a large hiatus hernia which was (mg/l)54.5 60.5 52.4 63.1 52.4 50.5 (p=n.s.) laparoscopically repaired with a cruraplasty and gastrodesis.[6 Prothrombin patients had laparoscopic conversion of a gastroplasty].In the time96.3 91.0 94.3 92.7 100.2 105.2 (p<0.05) remaining22 patients an open procedure wasutilised to facili- Conclusions :There was a 23% reduction of total body weight, tate conversion of previous gastric bypass or gastroplasty.The a 37% reduction of body fat, a 10% reduction Fat Free Mass Lap Band was inserted in the same position. (FFM), and a significant improvement of the metabolic profile. Results:The cohort comprised 85% females and 15% Modifications of body composition were maximal during the first males.Mean age was 41 with a range 15-70 yrs.Mean present- 6 months.The degree of weight loss was correlated to initial ing BMI was male 43.4 and female 42.1.Current BMI male 35.7 body weight and was more important in patients with abdominal /female 34.6.The mean presenting weight was 116Kg. Mean obesity.Reduction of FFM was positively correlated to waist cir- loss at 12months was 24Kg with a mean loss per month of 2.2 cumference (p< 0.0001).There was no evidence of vitamins and Kg .Mean excess weight loss was 50%. minerals deficiency 1 year after gastric banding. Complications:gastric perforation5 1.3% [3 perforations- microperforations secondary to sutures,{Band 62.FLEXIBLE GASTRIC BAND: SUCCESS OF INTERDIS- removed} 1 perforation secondary to slippage requiring partial CIPLINARY TEAM-WORK? gastrectomy and Band removal, 1 perforation due to erosion of Ricklin Thomas P .*, Potoczna Natascha*, Piec Grazyna*, Band/, Band removed laparoscopically, replacement Band at 6 Steffen RudolfX, Horber Fritz F.* X. *Clinic Hirslanden Zürich,X months and 1 gastric perforation at time of band insertion, OBEX-Institutes, Zürich and Bern, Switzerland laparoscopically sutured] Background:The definition of success of bariatric surgery Band leakage1 <1%Wound Haematoma2 <1% should include weight loss results, improvement in quality of life, Wound Infection6 1.5%Port site infection 6 1.5% reduction of comorbidities and rate of peri- and postoperative Port site fracture2 0.5% Port casing split2 0.5% complications.In 1996, BAROS (Bariatric Analysis and Port tubing leak2 0.5% Reporting System) was introduced and published by Oria et al. [all port related complications repaired local/sedation] (Obesity Surgery 1998;8;487-99). This standardised scoring Pulmonary Embolus 1 <1% system allows quantitative comparisons to be made between [warfarinised for 6 months no further sequealae] different methods and institutes. Slippage 20 5% Methods:Between 22.2.1996 and 30.10.1999, 249 patients Anterior Slippage 8 2% underwent implantation of a Swedish adjustable gastric band, Posterior Slippage 12 3.1% using a standardised technique. After two years, 199 patients Conclusion:Use of the laparoscopic gastric band { Lap Band} (81% female, 19% male, mean age 42 years, age range 18-70 is a minimally invasive approach to the problem of obesity. years) with BMI 41.8kg/m 2 (±0.3; SEM) were evaluated using Placement of the Lap Band at the esophago gastric the BAROS questionnaire, but 50 patients (20%) had not junctionreduces thepotential for posterior slippage.It provides answered the questionnaire, yet.However, there was no differ- an approach to the problem of obesity which is relatively low risk

394 Obesity Surgery,11, 2001 Crete Abstracts

64.LAP AROSCOPIC VERTICAL GASTRIC BANDING – in the field of bariatric surgery. The aim of this study was to FIVE YEARS EXPERIENCE. assess the effect of laparoscopic treatment of complications Eliezer Avinoah MD, Leonid LansdbergMD, Solly Mizrahi MD. linked to Vertical Banded Gastroplasty. SurgeryA, Soroka Medical Center, Faculty of Health Sciences, Methods:In a prospective study the outcome of patients with Ben-Gurion University, Beer-Sheva,Israel reoperation after VBG were analyzed. All reoperations from 500 morbidly obese patients underwent laparoscopic gastric September 1999 onward were planed laparoscopically .The banding during 1996 to 2001.Their mean age was 38±9 (range LAP-BAND System (LAGB) and the Swedish Adjustable Gastric from 12 to 67 years) years old and their BMI (body mass index) Banding (SAGB) are performed as laparoscopic procedures in 44 ± 7.There were 156 males and 344 (69%) females. Sixty the treatment of complications after VBG. (12%) patients had diabetes and 75 (15%) patients had essen- Results:Between September 1999 and April 2001 we oper- tial hypertension, 126 patients (82% of the males) had sleep ated 24 patients, who were admitted for a reoperation after VBG apnea syndrome. Four patients required convertion to open initially via laparotomy .All reoperations were planed laparo- surgery, because oftechnical difficulties.Duration of operation scopically.Six out of the 24 patients (25%) had multiple opera- at the first 250 patients was 80 ±25 minutes, while at the last tions.Indications for reoperations were: Nine patients (37%) 250 patients it declined to 39 ± 22 minutes. The band was with outlet stenoses and recurrent vomiting and 15 patients with inserted through the gastro-phrenic ligament from the angle of staple line disruption.The mean BMI prior treatment was 46.2 ± His to the lesser curve and fixed under the fundus.There was 5.4 kg/m2.The mean BMI decreased statistically significant until no mortality.Four patients had misplaced band and were reop- the complication occurred 34 ±6.3 kg/m 2.We noted no periop- erated two to three days after surgery. The erative complications and no conversion to open surgery, mean hospital stay after surgery was 22 ±13 hours.Eight to 14 respectively.The mean duration of operation were 85 ±14 min- months after surgery 21(4.2%) patients had band slippage.12 utes and the hospital stay 4.2 ±1.3 days.The mean follow-up patients of them had gastric band obstruction and underwent were 14 ±5,4 months and the current follow up rate is 96%.The laparoscopic reposition. Gradual inflation of the band induced strategy and technique of laparoscopic complication manage- gradual adaptation.Only ten percent of the patients reported of ment will be described in the presentation. recurrent vomiting.The mean BMI five years after surgery is 28 Conclusion:The treatment of complications after VBG with ±7, six patients of whom had laparoscopic band extraction.Our Laparoscopic Adjustable Gastric Banding (LAGB and SAGB) is conclusion is that laparoscopic gastric banding is an effective safe and effective. operationwith very low morbidity. 67.CONTRACEPTIVE THERAPY AFTER BILIO-P ANCRE- 65.SAFETY AND FEASIBILITY OF LAGB FOLLOWING ATIC DIVERSION IN THE TREATMENT OF MORBID PREVIOUS FAILED SRVG. OBESITY. Subhi Abu-Abeid, Ann Gorevich and Amir Szold. Surgery B, R.Ceulemans, E. Gerrits, L. Hendrickx, E. Totté, R. Van Hee Bariatric Surgery and advanced laparoscopic Surgery Unit, Tel- Academic Surgical Centre Stuivenberg, Antwerp, Belgium Aviv, Suorasky Medical Center, Tel-Aviv, Israel Background:An important population of patients who under- Gastric Restriction is the most common operation done for went a biliopancreatic diversion are fertile women.We would like morbid obesity outside the U.S.A.This operation can be done by to demonstrate the need for consensus with regard to contra- laparoscopy or laparotomy and include various gastric banding ceptive therapy after biliopancreatic diversion by evaluating the procedures and vertical gastroplasties ( VBG,SRVG). risks of pregnancy , the safety of oral contraception and the At least third of vertical gastroplasties will develop on a later changes in fertility after this type of obesity surgery. stage stapler line disruption, pouch dilatation and rarely silicon Methods:From May 1997 till May 1998 forty-one women ring widening or migration, these patients will eventually gain were included in a prospective study evaluating the hormone weight, and the question how can we help them overcome this status preoperatively and postoperatively on day 2, day 7, after life threatening situation. 13 patient (9M, 4F) who underwent 3 months, 6 months and 1 year. Women younger than 16 or previous SRVG’s (3 Æ15 years) (mean 6.5 years) were referred older than 44 years of age were excluded. One patient had a due to weight gain.Upper GI series showed stapler line disrup- total hysterectomy.All of the patients underwent a biliopancre- tion in 8, pouch dilatation in 4 and stoma enlargement in 1 atic diversion as described by Scopinaro with the modification of patient.All patient were operated through an upper midline inci- a 60 cm common limb.The three surgeons were free to choose sion.In all patients the repair was performed laparoscopically, the type of contraceptive therapy. An extensive questionnaire, adhesions were released and lap band was placed just below queering the fertility and obstetric history, was send at least two the G-E junction.There were no intraoperative complications, no years after inclusion. A literature search was performed to conversion and patients were discharged whith in 24 hours.the understand the complex physiology of hormone changes after short term results seems to be more than expected . excessive weight loss and absorption and metabolism of oral Although it’s a small number of patients, it seems that previous contraception in case of postoperative complications. failed gastric restriction operations can be done safely by Results:Evidence, found in literature, shows that rise in con- laparascopically .Longer follow up and more patients are centration of SHBG, FSH and LH and decreasing levels of needed to evaluate the long term result’s in this subgroup. serum testoster one and DHEA-sulph ate resulting in an improved fertility status, is regulated through complex interac- 66.LAP AROSCOPIC TREATMENT OF COMPLICATIONS tions as with the GnRH-pulsgenerator. In case of excessive AFTER VERTICAL BANDED GASTROPLASTY. weight loss, vomiting and diarrhoea oral contraception is less Karl Miller, Emanuel Hell. Krankenhaus Hallein and Ludwig safe.In case of postoperative complications a pregnancy may Boltzmann Institut fuer Gastroenterologie Hallein / Salzburg, enhance the morbidity of the patient and child as spina bifida in Austria case of folic acid deficiency.The lab results in our study indi- Background:Minimal invasive surgery is a great improvement cated the same trend in hormone changes as mentioned above.

Obesity Surgery,11, 2001 395 Crete Abstracts

The questionnaire shows the use of 5 different types of contra- OBESITY: COMPARISON AT ONE YEAR OF SCOPINARO’S ception where 9 patients used solely oral contraception.From BPD AND BPD WITH TRANSITORY GASTROPLASTY PRE- those, 2 patients (22%) developed an unforeseen pregnancy . SERVING DUODENAL BULB. For both it was their first child.From 4 patients using no contra- F.Mittempergher, E. Di Betta, C. Casella, B. Salerni. Chair of ception 2 got pregnant within 12 months after the operation. General Surgery, University of Brescia, Italy From the 4 pregnant women 1 developed anaemia and 1 vita- The aim of this study is to evaluate the results obtained using min deficiency.Although abortion and child complications were two malabsorpitive procedures for severe obesity. seen in other patients in our hospital, none of these problems A prospective randomised study was carried out from May 1999 were seen in our study.There were no obvious changes in the to May 2000. T wenty patients were operated on, 10 by the patient’s menstrual cycle or sexual activity. Scopinaro’s biliopancreatic diversion (group A) and 10 by the Conclusion:Although, in our small study group, no pregnancy BPD with transitory gastroplasty preserving the duodenal bulb related complications were seen, literature shows that preg- (group B).Controls were carried out at set intervals (1, 3, 6, 12, nancy should be avoided within 6 to 12 months after biliopan- 18 months after operation) to evaluate weight loss and the creatic diversion because of rare but potentially severe compli- metabolic effects of surgery in terms of glucose, iron, calcium cations for the mother and child.The fertility, as indicated by the and protein status. world literature and confirmed in our study , is better after bil- Age, body mass index and percentage of excess body weight iopancreatic diversion.Oral contraception is less reliable.There were similar in both groups. In the group A the weight loss is at present no consensus about the use of contraceptive ther- expressed as percentage of excess body weight (EW%L) was apy.We strongly believe that large multi-centre, prospective, 28.4% ±3.7%, 40.6% ±5.2% and 50.5% ±8.2% respectively 3, randomised trials are necessary to confirm our feeling that oral 6 and 12 months after the operation.In the group B the EW%L contraception should be avoided at least 6 to 12 months after was 38.6% ±5.3%, 51.0% ±4.2% and 65.8 ±1.1% respectively biliopancreatic diversion. 3, 6 and 12 months after the operation.The difference was not statistically significative.There was no hospital mortality in both 68.SHORT TERM COMPARISON OF “LONG-LIMB”ROUX- groups.Major complications did not occure in the group A, while EN-Y GASTRIC BYPASS VERSUS BILIARY P ANCREATIC in 1 patient in the group B (leakage of the gastric band). DIVERSION WITH “DUODENAL SWITCH”. Although we did not observe any major plasmatic reductions of T.Daskalakis, J.Nicastro, H.Mcmullen, S.Bianchi, M.Pagala, albumine, iron and calcium in both groups, patients in group B G.Coppa, J. N.Cunningham, J. Macura. Staten Island had major concentrations of albumine and iron than the other University Hospital, Staten Island, NY and Maimonides Medical ones (p>0.05). Center, Brooklyn, NY, USA Our results showed that both techniques are valid solutions One hundred forty-three consecutive procedures for morbid for the treatment of morbid obesity.The relatively more invasive obesity performed at our institutions between October 1, 1999 nature of the BPD with transitory gastroplasty preserving duo- and October 1, 2000 were reviewed.Of these, ninety-three were denal bulb makes, in our opinion, the Scopinaro’s BPD the first “long-limb”Roux en Y Gastric Bypasses (LLRYGB) and fifty surgical approach for severe obesity .Nevertheless, the BPD were biliary-pancreatic diversions with “duodenal switch (DS)”. preserving duodenal bulb could be a good choice in cases We compared the two procedures in terms of hospital length already treated by a gastro-restrictive operation with unsatisfac- of stay, complications, and early weight loss.In terms of weight tory result. loss, we further subdivided the groups into 3 levels of morbid obesity based on their Body Mass Indexes.A stastical analysis 70.COMP ARISON OF MICRONUTRIENT DEFICIENCIES using unpaired t-test and z-test were performed to evaluate our AFTER ROUX-Y GASTRIC BYPASS AND BILIOPANCRE- results. ATIC DIVERSION WITH ROUX-EN-Y GASTRIC BYPASS IN We found that the DS is associated with, a slightly longer MORBID OBESITY. hospital length of stay, 6.08 days vs.3.88 days (p<0.001), and a Skroubis George*, Sakellaropoulos George**, Mead Nancy *, higher incidence of superficial wound infections compared to Nikiphoridis George**, Kalfarentzos Fotis*. Nutrition Support LLRYGB, 10.00% vs.1.07% (p<0.020).Among all patients, the and Morbid Obesity Clinic, Surgical Department* and decrease in BMI and weight loss rate is comparable.In males, Department of Medical Physics**, School of Medicine, there is a statistically significant greater decrease in BMI in the University of Patras, Greece LLRGYB patients than in DS patients up to 12 months, while in Background:Patients who underwent either Roux-Y gastric females it is comparable.By subdividing the patients into 3 lev- bypass (RYGBP) or biliopancreatic diversion with Roux-Y gas- els of BMIs (<50, 50-60, >60), there was no significant decrease tric bypass (BPD with RYGBP) are at risk of developing meta- in the DS patients.The LLRYGB patients with <50 BMI had a bolic sequelae as a consequence of malabsorption.The aim of greater decrease in BMI at 12 months compared to patients with this study is to compare the potential differences in micronutri- BMI of 50-60 and a greater decrease in BMI at 1 month and at ent deficiencies between these two types of bariatric operations. 12 months compared to patients with BMI>60. Methods:This is a retrospective analysis of a prospective At this early follow-up, DS does not demonstrate an advan- database.From June 1994 to April 2001, 196 morbidly obese tage in terms of weight loss over LLRYGB.As expected, hospi- patients underwent various bariatric procedures at our institu- tal length of stay is somewhat greater.Complications are com- tion.Of these patients, 78 (mean BMI 45.7, SD=4.8) who under- parable with a slight increase in superficial wound infections. went RYGBP (gastric pouch 15 ± 5ml, alimentary limb 80- The graphic representation of weight loss suggests that our 100cm, cholopancreatic limb 60-80cm), and 60(mean BMI 56.6, results may change significantly with further follow-up and re- SD=6.2) who underwent BPD with RYGBP (gastric pouch 15 ± evaluation at the 18-24 month probably is warranted. 5ml, alimentary limb 350cm with common limb 100cm), were selected and studied for the incidence of micronutrient deficien- 69.BILIOP ANCREATIC DIVERSION (BPD) FOR SEVERE cies at 1, 2 and 3 years postoperatively .After surgery, all

396 Obesity Surgery,11, 2001 Crete Abstracts patients received a multivitamin and mineral supplement daily. prescribed as a routine. At the present check-up during year Oral calcium supplementation was administered at a dose of 2000, all 28 patients still alive (eight patients were dead) had a 1gr/day in RYGBP patients and 2gr/ day in BPD with RYGBP clinical examination and biochemical tests. T wenty-one of 23 patients.An oral iron supplement was prescribed only for pre- patients with a functional shunt had bone density measured and menopausal women at a dose of 80mg/ day, independently of 15 patients agreed to collect feces for measurement of fecal fat. the type of operation.Starting at 6 months postoperatively, vita- Results:Ten of 36 patients (28 %) had had their shunt min B12 supplementation was given IM at a dose of 1000-3000 reversed.With one exception all these patients quickly regained mg, depending on measured values. A variety of nutritional weight, and five of them (50 %) are dead.Causes of death were; parameters including Ht, Hb, Fe, ferritin, folic acid, vitamin B 12, cardiac failure (2), septicemia (1), suicide (1), cerebral bleeding calcium and phosphorus, were measured preoperatively and (1).At death three of the five patients (60 %) were on treatment postoperatively at 1, 3, 6, 12, 18 (BPD with RYGBP pts) and 24 for diabetes mellitus and hypertension. months, and yearly thereafter. 23 patients with an intact JI shunt were alive, but five of them Results:The nutritional parameters investigated are shown in (22 %) had had the shunt shortened due to weight gain.After the table below: reaching stability the weight loss has been maintained.Despite a median age of 56 years (range 48 – 80) none of the patients Type of Operation with an intact JI shunt have developed coronary heart disease RYGBP BPD with RYGBP and none were on treatment for diabetes mellitus. of pts/no of points/no. Malabsorbtion of fat is still present.Blind loop syndrome, flatu- with deficiency/ of points with deficiency lence, foul fecal smell and diarrhoea are the most troublesome % points with deficiency% points with deficiency long term sequela. Deficiencies in vitamin D, vitamin E, iaar arsars ear earsars Calcium, Magnesium and Zinc are common, and 48 % received /41./ 55./ 66.27.7 / 37.5.3.3 vitamin B12 supplement. T wo of 21 patients (age 80 and 57 /20./ 36./ 5018.7 4/ 255.5 years) had osteoporosis.Three patients with an intact JI shunt in7/ 346/ 4752.9 / 91./ 6.25./ 0 had died and the causes of death were;Intestinal ischemia (1), acid0/ 00/00/00/0 /0/0 /0 alcoholic hepatitis (1), carcinoma of the pancreas (1). /18./ 30.16.6 27.7 / 31.24.4 Conclusion:When the optimal length of shunt is found, JI bypass maintains a significantly reduced weight for 25 years. /2.1.0/ 00/00/0 /0/0 /0 Vitamin and mineral deficiencies are common, but no serious 0/00/00/00/0 /0/0 /0 clinical deficiency states are seen. Normal values: Hb: men>13.5g/ dl-women>12.5g/dl, Fe:>50mg%,

Ferritin:>9ng/ml, Folic Acid:>1.5ng/ ml, B 12:>200pg/dl.Ca:>8.5mg/ dl, 72.IMPROVEMENT IN INSULIN LEVELS AND INSULIN P:>2.5mg/dl. RESISTANCE AFTER BILIOP ANCREATIC DIVERSION IN Values of the nutritional parameters were compared at simi- MORBID OBESITY WITH AND WITHOUT DIABETES TYPE II. lar periods postoperatively between the two groups.No statisti- Maria Laura Cossu, Enrico Fais, Matteo Ruggiu, Claudio cal difference (p<0.05) was observed between the groups for Sparta, France Cossu, Giuseppe Noya. Department of emer- any of the nutritional parameters studied.All the micronutrient gency surgery – University of Sassari, Italy deficiencies were mild, without clinical symptomatology and Background:The purpose of our study was to determine the were easily corrected with additional supplements of the defi- actual metabolic effects of biliopancreatic diversion, particularly cient micronutrient with no need for hospitalization. of the diversion itself, on glyco-lipid metabolism and expecially Conclusion:There was no statistical difference in the on insulin resistance and insulinemia levels, in morbid obesity micronutrient parameters studied following RYGBP vs.BPD with and without diabetes II. with RYGBP.The most common deficiencies encountered were Method:Since 1998 three groups of patients, 22 with morbid of iron and vitamin B12. The incidence of Ca deficiency was obesity without diabetes II, 26 with morbid obesity and diabetes essentially nonexistent, and no deficiencies of phosphorus or II, and 19 with slight obesity and diabetes II, have been treated. folic acid were observed. They were submitted to pre and postoperative assays of fasting glycemia and insulinemia, and an assay of the lipidic parame- 71.JEJUNOILEAL BYP ASS – STATUS 25 YEARS AFTER ters.In the first group of patients who were without diabetes II THE OPERATION. or IGT and had a normal fasting glycemia, the mean preopera- Villy Våge1, Jan Helge Solhaug 2, Asgaut Viste 3, Arnold Berstad 4 tive was BMI 49.66;we performed the classic biliopancreatic Department of Surgery , Fø rde 1, Deakon Hospital, Oslo 2, diversion.In the second group , the mean preoperative BMI was Department of Surgery 3 and Department of Medicine 4, 53.19;21 patients had diabetes II and 5 had IGT.We performed Haukeland University Hospital, Bergen, Norway the original biliopancreatic diversion also in these patients.In Background:Jejunoileal (JI) bypass with ileocolostomy or the last group the mean preoperative BMI was 34.15:16 patients ileojejunostomy was a widely performed procedure for morbid had diabetes type 2 and 3 patients had IGT;13 patients were in obesity in the 1970’s. The operation leads to intestinal malab- treatment with tablets and/or insulin.In this group we performed sorption and was effective in reducing weight but was aban- the biliopancreatic diversion without gastric resection and with doned due to its side effects.The purpose of this study was to the pylorus preserving technique. evaluate the long-term results following JI bypass at a Results:The results regarding the glycolipidic and insuline- Norwegian University Hospital. mia metabolism in the groups of patients were very satisfactory, Method:From november 1971 until september 1976 a total of as summarized in the following table: 36 patients were operated. Median age at operation was 33 1) BPD with gastric resection on 22 patients without diabetes 2 years, median BMI 42 kg/m 2.Shunt lengths varied between 45 PREOPERATIVE6 MONTHS P and 60 centimeters.Vitamin and mineral supplements were not BMI 49.66 35.37

Obesity Surgery,11, 2001 397 Crete Abstracts

Glycemia 90.5±2.39 77.1±2.04 <0.001 long term period after NAGB) by Wilkinson – Peloso increase Isulinemia 26.81±5 10 8.48±4.45 0.0245 weight in consequence of excessive restriction of proximal 2) Classic BPD on 26 patients with diabetes II pouch of the stomach occur.GB with proximal pouch 20 – 30 ml PREOPERATIVE6 MONTHS P give weight loss 35 – 43% except “ sweet-eaters syndrome” BMI 53.19 39.08 patients, but lipid profile decreased inadequate. Mean weight Glycemia 138.2±11 84.2±2 <0.001 loss in patient with BIB was 19.5 kg (12-28), 1 case of balloon Insulinemia23.70± 3.6 9.87±1.89 0.002 intolerance and 1 unsatisfactory case occured.After BPD and 3) BPD without gastric resection on 19 patients with diabetes II RYGBP in 3 month weight loss was 21.5 ±3.8 (14.8%) and 28 PREOPERATIVE6 MONTHS P ±2.9 (16%) with normalization of the blood lipid values. BMI 34.15 28.1 Conclusion:Gastric banding – effective and safe weight Glycemia 153±17 98.4±4.1 0.0128 reduce method in patient with BMI <50 kg/m 2 without consider- Insulinemia28.35± 2 10.8±1.3 <0.001 able hyperlipidemia.The optimal method in patients with super Comparative Analysis: morbid obesity and sweet-eaters syndrome – gastric bypass or Preop.glycemia p:0.0008 group 1 vs group 2 and 3 BPD Scopinaro method. Intragastral balloons are effective in 6 months Glycemia p:0.03 group 2 vs group 3 patients with initial form morbid obesity and in patients with Preop.Insulinemia p:no statistical difference in the super obesity for preoperative preparation. gropus 6 months Insulinemia p:no statistical difference in the groups 74.EARL Y EXPERIENCE WITH LAPAROSCOPIC BIL- Conclusion:The comparative analysis of global values indi- IOPANCREATIC DIVERSION (LBPD). cates that biliopancreatic diversion without gastric resection has Roberto M. Tacchino, Maurizio Foco, Gianni Greco, Marco the same beneficial effects in glycolipidic and isulinemia metab- Castagneto. Department of Surgery , Catholic University SH, olism and suggested that this improvement is due to the bil- Rome, Italy iopancreatic diversion .The duodenal switch technique seems Background:Biliopancreatic diversion is a well-established to be a surgical option in cases of slight obesity associated with procedure with excellent weight loss and long term results. serious glyco-lipid alterations. Laparoscopic approach has been used successfully for many bariatric procedures and proved to be safe and effective in 73.CHOICE OF OPTIMAL BARIA TRIC PROCEDURE IN reducing postoperative morbidity.Biliopancreatic diversion is a THE TREATMENT OF MORBID OBESITY. well-established open procedure that ensures excellent weight A.S.Lavryk, V.F.Sayenko, O. S.T yvonchuk, O. P.Stetsenko, T. loss.Recently a laparoscopic BPD with duodenal switch has V. Masurak. Institute of Surgery & Transplantology, Kyiv, Ukraine been successfully performed.We report our early experience of Background:The problem of morbid obesity (MO) can be laparoscopic BPD with gastric resection (Scopinaro procedure). decide by surgery only .There is no ideal operation for morbid Development of a laparoscopic technique allows the same oper- obesity and there probably never will be one.We present results ation without abdominal incision and lower postoperative dis- of the surgical treatment of MO over the last 18 years, including: ability. jejunoileal bypass(JIB), various gastric restriction procedures, Methods:The operation is performed with five lap ports. intragastric balloon, distal gastric bypass, biliopancreatic diver- Gastro-epiploic vessels, right and left gastric artery are coagu- sion (Scopinario).We can divide our experience on two periods. lated and divided. Duodenum and stomach are sectioned by Methods:First period:from 1983 till 1997, when we did 64 JIB three to four applications of linear stapler.We then proceed to in various variants – by Scott – 3, by Buchwald – 8, by Payne- the identification of the ileocecal valve. Measurement of the De’Wind –15, by our method – 38;1 gastric bypass by Griffen; ileum is made against a calibrated clinch in steps of five cm with 34 – nonadjustable gastric banding (NAGB) by Wilkinson – the small bowel fully stretched.The 50 and 250 cm points are Peloso and 2 VBG. In this group mean weight of the patients identified and marked. Section of the ileum and mesentery is was 210kg (160 ±290), BMI > 55 kg/m 2, mean age 36.5 (18 – made by linear stapler. Ileoileal anastomosis is made side to 55).Second period was opened from 1997 we performed 41 side with linear stapler.Dissection through the mesocolon close gastric banding(GB):8 – adjustable (Lap Band BioEnterics), 33 to the Treitz is the next step and the alimentary limb is brought – nonadjustable (Kuzmak – small pouch).Mean age was 35 (. up to the gastric stump.The gastro-entero anastomosis is com- Mean weight was 158 (95 – 223) kgs.BMI was 53.6 kg/m 2 aver- pleted with a 60mm linear stapler.In order to avoid increased age.BioEnterics Intragastric balloon (BIB) was implanted in 8 risk due to excessive operative time, we imposed a time limit of patients (2 males and 6 females) .Mean age was 38 (35 – 45) four hours, after which the procedure was converted to an open years, mean weight was 169 kg.(95 – 220) mean BMI was 52 one.Fourty consecutive patients underwent laparoscopic BPD kg/m2 (35 – 70).In 3 patients with BMI > 55 kg/m 2, age 30 to 37 form April to March 2001. years (2 females and 1 males) distal Roux –en- Y gastric bypass Results Twentyfive patients were completed laparoscopically. (RYGBP) were performed.In 2 patients were performed Wood The conversions were always due to time limit.One patient was modification (Total length of limb - 400 cm, common of limb - complicated by an anastomotic leak requiring reoperation.Early 200 cm), and in 1 – Torres and Oca “for sweet eaters“ modifica- case results show no perioperative mortality , acceptable mor- tion (Total length of limb - 245 cm, common of limb - 152 cm).In bidity and weight loss comparable to open cases. 2 females (BMI > 55 kg/m2 ) – BPD Scopinaro Conclusions :This very complex advanced laparoscopic pro- Results:In the group with JIB was significant weight loss, with cedure still needs improvemen t of technical details. an average of 62± 17 kg lost in 24 months following surgery . Laparoscopic biliopancreatic diversion is a feasible alternative High amount of postoperative complications (bypass-enteritis to the open operative procedure. 24.3%, excessive malabsorption 18.3%, renal stones 2.2%, and gall stones 2.2%, metabolic disorders – 1.28%) make refused of 75.LAP AROSCOPIC BILIOPANCREACTIC DIVERSION – this operation. GB showed acceptable weight loss results. In TECHNIQUE AND INITIAL RESULTS.

398 Obesity Surgery,11, 2001 Crete Abstracts

Dyker Paiva, MD, Lucineia Bernardes, MD; Livio Suretti, MD . gun.T echnique shown here is a completely laparoscopic intra- Surgical Department - Mater Dei Hospital, Belo Horizonte, abdominal procedure which avoids sending trans-oral instru- Brazil mentation and eliminates the need to insert the EEA gun Background:Bilio-pancreactic diversion (BPD), idealized by through the abdominal wall with problems with gas leak and Scopinaro, is a method provenly efficient in treating morbid obe- wound sepsis. sity.Using the laparoscopic technique, it is possible to reduce The patient in this video also had a symptomatic hiatus her- the number of complications related to conventional surgery , nia which was treated by reduction of the hernia and a crural such as in-hospital time, respiratory complications, early return repair.A cholecystectomy is performed as part of the Scopinaro to work and incisional hernia. procedure. Methods:From July 2000 to April 2001, 40 patients were sub- The author has performed one hundred and three laparo- mitted to laparoscopic BPD: 29 women and 11 men, with an scopic Scopinaro bypasses, twenty-seven standard and sev- average age of 39 (range = 17 to 60). Average IMC = 43.6 enty-six with sleeve and duodenal switch as shown here. kg/m2.The employed technique strictly followed the original, with the following stages:(1) cholycestectomy;(2) large skeleti- 77.LAP AROSCOPIC DUODENAL SWITCH:TECHNICAL zation, gastric curvature, and duodenal section 2 cm below the ASPECTS. pylorus;(3) skeletization of the small gastric curvature;(4) gas- A.Baltasar, R.Bou, J.Miró, M.Bengochea, N.Pérez. Hospital tric section;(5) measurement of the small bowel as of the cec- “Virgen de los Lirios”, ALCOY.Alicante. Spain. cum;(6) ileoentero anastomosis at 50 cm of the ileo-ceccal Background:The Duodenal Switch is a variation of the bilio- valve;(7) passage of the alimentary limb through the meso- pancreatic diversion surgery for obesity .Vertical subtotal gas- colon;(8) 35 mm linear gastroentero anastomosis.All of these trectomy, division of the duodenum and BPD is done with a procedures will be presented on video.Seven of these patients Common loop of 75 cm, Digestive loop of 250 cm and 250 cm were submitted to the removal of the adjustable gastric banding of bypassed proximal small bowel.Open surgery was done until and converted to BPD.All were submitted to a cholecystectomy; recently.The laparoscopic technique is presented in video. one patient was submitted to an umbilical hernioplasty.Follow- Methods:Twelve patients have been operated on by the up is still in progress.Patients are seen at the clinic monthly up laparoscopic aproach.Six trocars are used.Devascularization to the sixth month and, subsequently, every three months, with of the greater curvature of the stomach and proximal duodenum blood tests every three months. is done with the harmonic scalpel.The duodenum and the stom- Results:All surgeries were carried out successfully through ach resection are done with linear staplers.The variation in the laparoscopy.Excess weight loss was 91% in four patients who technique compared with the open method have been the ante- are in the tenth post-operatory month, 75% in two patients in the rocolic position of the digestive loop.The end-to-side duodeno- eighth month, and 48% in three patients in the sixth month. ileal anastomosis is hand-sutured. The side-to-side entero- Mortality was 2.5% (one patient in the fifth day after surgery , enterostomy of the digestive and biliopancreatic loops is done due to massive pulmonary emboly).The average operation time with a linear stapler and the enterostomies closed by hand- was 210 minutes (range:130 to 480), and the average length of suture.The mesenteric defects are not closed. hospital stay was 4.3 days (range:3 to 21).There were five spe- Results:Operating times ranged from 3:15 to 5:30 hours. cific post-operatory complications (12.5%): two pulmonary One patient required 5 units of pack cells due to bleeding of the embolies;2 bleedings in the staple line;one fistula.Later com- vertical subtotal gastrectomy staples line even after a serosa- plications totaled six (15%):3 (7.5%) cases of diarrhea up to the serosa hemostatic continous suture line. One case was con- fourth month, 2 cases (5%) of elevated PTH and normal cal- verted due to stapler failure.Postoperative stay was 4 - 9 days cium, and one (2.5%) case of hypothyroidism that was difficult (mean 5). to control clinically. Conclusions :The Duodenal Switch can be done laparoscop- Conclusion:BPD may be executed through laparoscopy with- ically with the same principles as in the open method.Although out changes in the original technique, increase in risks or com- the operative times are longer the technique seems suitable as plications and without jeopardizing results. an alternative.

76.LAPAROSCOPIC SCOPINARO WITH DUODENAL 78.SWEDISH ADJUST ABLE GASTRIC BAND (SET P AT- SWITCH AND ASSOCIATED CRURAL REPAIR AND CHOLE- TERN). CYSTECTOMY. Antelmo Sasso Fin. Hospital São Luiz, Brazil George A Fielding. Wesley Hospital and Royal Brisbane The band will be better placed if you put it below the lowest Hospital, Brisbane, Australia point of the right diaphragmatic pillar and above the left gastric The duodenal switch variation of the Scopinaro bypass has artery tunneling carefully through the connective tissue behind gained some favour.Certainly with laparoscopic application it is the retoperitoneal part of stomach coming through the gas- technically easier than a standard Scopinaro which involved a trophrenic ligament.Do not dissect through the phrenic aponeu- distal gastrectomy.It has the added advantage of maintenance rosis because sometimes it is difficult prenetrate. of the antrum and first part of the duodenum with pylorus. The position of the flaps of the band may be on the left side The video shows a technique for duodenal switch with gastric or right side without affecting the results.The operator should sleeve resection using a standard Scopinaro 50cm common choose the location must convenient for him based on the channel and 200cm roux limb.It also shows a side to side sta- anatomy, taking care not to leave enough of the stomach wall pled anastomosis between the first part of the duodenum and free to permit slippage to occur; remembering that later the the roux limb.This is the author’s preferred technique and is dif- entire anterior transverse diameter of the stomach must be used ferent to what has previously been described for this procedure. to establish the tunnel and that the wall should only approximate The previous descriptions have involved use of a trans-oral pas- the band loosely allowing only enough space to accommodate sage of an EEA anvil and trans-abdominal insertion of an EEA inflation of the band without traction on the stomach covering

Obesity Surgery,11, 2001 399 Crete Abstracts the band.This consideration avoids erosion of the stomach wall the laparoscopic adjustable gastric banding operation (LASGB) when the band is maximally inflated (9ml). with the 9.75 or 10 cm LAP-BAND ® (Bioenterics, Carpinteria, Ca, USA) was approximately 10%. Changing the operation 79.LAP AROSCOPIC BILIOPANCREATIC DIVERSION FOR technique to include the fatty tissue of the lesser curvature MORBID OBESITY. within the band, the so-called pars flaccida technique, led to a Joaquin Resa, Jorge Solono. Hospital Royo, Villanova, reduction in the slippage rate to almost 0%.For this purpose the Zaragoya, Spain. length of the band had to be increased to 11cm.The volume of Over the last 25 years the biliopancreatic diversion has been the circumferential inflation membrane on the inner surface of successfully used as one of many surgical treatments to the band is now 9cc instead of 4 cc for more convenient adjust- achieve significant long term weight loss.However, this proce- ment of the stoma diameter. dure was not free of post operative complications.We think that Methods:The video describes the operation technique of the using a mini-invasive approach a big incision is spared, result- new 11cm LAP-BAND ® applied at our institution including posi- ing in a faster recovery time with less pain and prompt ambula- tioning of the patient, trocart placement, the use of liver retrac- tion.Our procedure is a modification of the technique described tion hook and abdominal wall suspension device. by Scopinaro and it consists of a distal gastrectomy with a long Roux-en-Y reconstruction (Video presentation). Patient in the 81.GASTRIC POUCH DILATION FOLLOWING LAGB SYS- supine position with head-up tilt with the surgeon operating TEM PROCEDURE: THE ITALIAN EXPERIENCE. between the legs of the patient.The main monitor should go at L.Angrisani, F.Furbetta, S.B. Doldi, N.Basso, M.Lucchese, M. the head of the table.The laparoscope is first placed through an Giacomelli, M.Zappa, E.Lattuada, L.Di Cosmo, A.Veneziani, umbilical port (10 mm) and initial inspection of the peritoneal G.U. Turicchia, F.Favretti, M.Alkilani, P.Forestieri, G.Lesti, F. cavity performed.We favors a 30-degree forward-oblique view- Puglisi, M. Toppino, F .Campanile, F .D.Capizzi, C. D’ Atri, L. ing laparoscope Two additional left upper quadrant trocars (12 Scipioni, C. Giardiello, N. Di Lorenzo, S. Lacitignola, M. mm) and a right upper quadrant trocar (12 mm) are placed Belvederesi, B.Marzano, G.Bernante, A.Luppa, V.Borrelli, M. under direct vision. Lorenzo. Italian Group for Lap Band, GILB, Naples, Italy The site of incision is determined at the greater curvature. Background:Gastric Pouch Dilation (GPD) is the most fre- Then we begin mobilizing the greater curvature and continue quent complication of Laparoscopic Adjustable Gastric Banding the mobilizati on toward the duodenum. This detachment (LAGB) System procedure. requires traction of the stomach by an atraumatic grasper by the Methods:Patients suffering one or more episodes of GPD assistant and is performed with the harmonic scalpel.Next pass have been selected from the data registry of the Italian Group a grasper along the posterior aspect of the stomach and then for LAP-BAND (GILB), which collect patient’s data from January through an avascular window in the lesser omentum. At that ‘96.Peri-gastric dissection with 9.75cm band was always per- time, we divide the duodenum with an Endo GIA stapler, 45 mm formed.Intra-operative pouch calibration varied between cen- long with 3,5 mm staples well beyond the pylorus. Carefully tres. inspect the staple line and reinforce it with interrupted sutures Results:Data from 28 centres with different level of experi- when necessary.Select the proximal transection site.The Endo ence (minimum 11, maximum 411 Pts) were available. 89 GIA stapler, 45 mm long with 3,5 mm staples is then fired three (6.2%) out of 1437 LAGB‚ operated pts. developed a gastric times as shown horizontaly.In addition the coronary vessels are pouch dilation:71, 14, and 4 pts.presented one, two or three also divided with a Endo GIA II stapler, but this time using the episodes respectively.33 (37.1%) pts.were without symptoms. vascular load (45 mm length, 2.0 mm staples). In the remaining, the most common clinical presentation was In order to create the Roux-limb, the jejunum is divided 50 cm vomiting (n=31; 34.8%). Diagnosis was made by Rx barium beyond the ligament of Treitz by using an Endo GIA, 45 mm long meal or gastrographin in all but two pts.Conservative treatment with 3.5 mm staples.In addition the mesentery is divided with a with band deflation was performed in 42/ 89 (47.2%) pts. harmonic scalpel. Surgical treatment under general anesthesia was performed in A retrogastric-retrocolic tunnel is performed in the mesocolon 47/89 (52.8%;) pts;3.8% of 1437 operated cases.Laparoscopic anterior and lateral to the ligament of Treitz.This "window" will access was preferred for:debanding (n=19;40.5%) and band facilitate the passage of the Roux-limb. repositioning (n=26; 55.3%) while gastric bypass (n=1; 2.1%) The Roux-limb is measured from caecum to 50 cm in ileon and oesophago jejunostomy (n=1; 2.1%) were performed length.An side-to-side anastomosis between the proximal laparotomically.Considering the sequential number of patients jejunum and the Roux-limb is created by firing a Endo GIA II sta- operated per centres which have developed GPD: 57/89 Pts plers.The enterotomy is closed using another load of staples. were observed within the first 50 operated cases, 19 Pts were The Roux-limb is now advanced trough the mesocolic window recorded between cases 51-100, 8 between cases 101-150, 2 (retrocolic) near the transected stomach when is fixed with inter- and 1 patient between cases 151-200 and 201-250 respectively. rupted sutures. Following an enterotomy an anastomosis Conclusion:The learning Curve in terms of surgical tech- between the gastric pouch and the Roux-limb is created by fir- nique and patient management play a fundamental role in ing a Endo GIA II.The enterotomy is stapled shut with another reducing the incidence of Gastric Pouch Dilation following load of Endo GIA II. LAGB. Finally we remove the specimen through umbilical port. 82.LONG-TERM RESULTS OF LAPAROSCOPIC ADJUST- 80.THE PARS FLACCIDA TECHNIQUE IN LASGB-OPERA- ABLE GASTRIC BANDING IN THREE MAJOR CENTRES IN TION WITH NEW 11CM LAP-BAND ®. BELGIUM. Ralph Peterli, Peter T ondelli. Surgical Clinic, St.Claraspital M.Belachew*, C. Desaive**, P.Belva***.*Chr Huy, **Chu Liege, Basel, Switzerland ***Chu Charleroi, Belgium Background:The slippage rate of the perigastric approach in Background:The authors will present long term results of

400 Obesity Surgery,11, 2001 Crete Abstracts

Laparoscopic Adjustable Gastric Banding (LAGB%) for the authors recommend taking two steps: treatment of morbid obesity. - Firstly, placing the 10.0cm LAGB in the pars flaccida position. Material and Methods :763 underwent LAGB operation in 3 There was no slippage in 103 patients who underwent surgery major surgical centres in Belgium, sharing the same criteria for between January 2000 and September 14, 2000 (Twenty-seven patient selection and the same surgical protocol standardized repositioning procedures were necessary during the same post- after the learning curve (i.e.virtual pouch, 3-4 anterior gastro- surgical period with the original technique and the 9.5cm band). gastric sutures and band left empty).Sex ratio:22% M / 78% F; -Secondly, placing an 11.0cm LAGB with a wider balloon that Mean age:34yrs; Mean BMI:42kg/m 2 (35-65).Data regarding cannot roll up, in the pars flaccida position, in order to prevent complications, reoperations and BMI evolution were collected slippage without risk of migration.This band is the new genera- during a follow-up period of minimum 4 years.Risk of stomach tion LAGB.T o date, from September 15, 2000 through April 15, slippage and pouch dilatation in relation to time was also statis- 2001, of the 123 bands that have been placed, no early dilata- tically evaluated (Kaplan- Meyer curve). tion has occurred. Three early cases of major dysphagia in Results:Mean BMI drops to 30kg/ m 2 during the first 24 patients with pre-operative esophagitis have led to reoperation, months.After this period, there is a moderate weight gain but but this has been prevented in subsequent cases by pre-opera- BMI stabilizes after 4 years at around 30 kg/m 2.Few peri-oper- tive medication of patients with GERD. ative complications were observed: Gastric perforation (4), In this way, the authors hope to contribute to improving the bleeding (1), colonic perforation (1).Conversion rate:1.3%. Late results with the laparoscopic gastric banding technique, which, complication:No trocar site hernia. T otal and irreversible food despite its drawbacks, still remains an effective, least aggres- intolerance due to stomach slippage was observed in 59 cases sive and most easily reversible technique for the surgical treat- (8%).Gastric erosion was detected in 7 patients (1%).Access ment of morbid obesity. port problems ( tilting of the port, broken tubing, port infection) occurred in 20 cases (3%).Risk of slippage decreases with time 84.LA TE OUTCOME OF ADJUSTABLE GASTRIC BAND- and gets stabilized at 30 % (of all slippage) at 54 months.Re- ING FOR SURGICAL TREATMENT OF MORBID OBESITY. operation:Band removal: 24(3.3%); Band replacement: 2 Cornelius Doherty, MD, FACS, James W. Maher, MD, FACS, (0.3%);Open re-positioning: 9 (1.7%); Laparoscopic re-posi- Debra Heitshusen, RN, BSN. Department of Surgery, School of tioning:45 (6%). Medicine, University of Iowa, Iowa City, Iowa, U.S.A. Conclusion:After the leaning curve which ended at the begin- Background:This prospective study reports long term, (>7 ning of 1995, we think that the problems related to surgical tech- years), follow up of patients who had adjustable silicone gastric nique have been solved.Material has also improved (injection banding, ASGB, for treatment of morbid obesity. port).The complication rate is stable and acceptable. Stoma Methods:Subjects were 45 kg or more overweight and had adjustment remains possible and useful even after years. no prior history of surgical treatment of their obesity.All had a Patient selection , good follow-up and multi-disc iplinary history of being obese 5 years or more and had failed to sustain approach are mandatory for the future of the procedure. weight loss with calorie restriction and behavior modification programs.The adjustable gastric band was placed at laparo- 83.LAP-BAND, PREVENTION OF SLIPPAGE: SERIES OF tomy around the fundus and tightened to create an outlet chan- 1410 PATIENTS:SWITCHING FROM THE 9.5/10.0 BAND TO nel of 12 mm and a proximal pouch of 25 ml. Subjects were THE NEW GENERATION 11.0 BAND. withdrawn from the study, if the band was removed, or if they Jean-Marie Zimmermann, Michel Blanc, Pierre Mashoyan, Érick requested withdrawal at any time. Zimermann, Jean-Marc Grimaldi. Clairval Private Hospital Results:Between March 17, 1992 and may 1, 1995, 26 Center, Marseille, France females and 14 males entered the study .Mean age was 34 The authors present a review of their LAP-BAND System years, (range 19-51 years).Mean height was 171 centimeters, (LAGB) experience, commencing in July 1995.From July 1995 (range 152-190 cms).Mean weight was 147 kilograms, (range through April 2001, 1316 patients underwent surgery. The 100-214 kgs).Mean Body Mass Index was 50, (range 39-75). series meets the same criteria as the series in the literature: There was no operative mortality.Mean Body Mass Index and mean age 41 years (17- 65), mean BMI 43 kg/m 2 (35-80), mean Mean Percentage Excess Weight Loss were reported only for weight 114 kg (83-230), mean excess weight 43 kg, 85% subjects with an intact functioning adjustable gastric band sys- women to 15% men, and 174 patients with a BMI greater than tem.Post operative mean Body Mass Index at 1 year one was 50 (14.1%).The materials used were 1090 LAGB (original ‘peri- 39, 2 years 38, 3 years 32.8, 4 years 36.5, 5 years 40.6, 6 years gastric’technique), 103 LAGB (‘ pars flaccida’ technique), 123 44.3, 7 years 39.6, 8 years 44.1.Post operative mean % Excess 11.0cm LAGB (‘pars flaccida’technique). Weight Loss at 1 year was 44%, 2 Years 47%, 3 years 32.8%, 4 Slippage has been reported more frequently (up to 18% in years 39.8%, 5 years 30.3%, 6 years 31.8%, 7 years, 33.1%, 8 the literature) with the LAGB, contrarily to the SAGB. This years 32%.T wenty-one intraabdominal reoperations were nec- occurred 129 times with the LAGB using the original technique essary to correct complication s related to the implanted on 1090 patients, i.e., 11%, including seven cases with repeated adjustable silicone gastric band. The problems were: 2.5% slippage.With the Swedish band, there are two significant dif- infected band, 5.0% obstructive aneurysmal deformity of the ferences:the position in contact with the diaphragm and not with inflatable bladder segment of the band, 17.5% enlarged pouch the stomach, and a wider balloon that consequently com- with obstructed outlet channel (mean time of occurrence 44 presses a greater width. months;range 21-88 months), 27.5% with herniation of the dis- Migration is most frequent (up to 4.6% in the literature) with tal stomach through the band into the posterior lesser sac caus- the SAGB. This band has a balloon that rolls up in the event of ing life-threatening obstruction (mean time of occurrence 32 “overinflation,”and allows the sharp edge of the band to come months;range 21-68 months.T wenty-two and a half percent of in contact with the visceral layer, creating a point of friction, subjects have voluntarily withdrawn from the study .After 109 whence the possibility of erosion.To palliate these problems, the months only 13 subjects remain in the study.

Obesity Surgery,11, 2001 401 Crete Abstracts

Conclusion:Progressive loss in efficacy of the ability of the another, but simply needs to be opened, repositioned and ASGB to maintain a significant decrease in BMI was observed closed as a simple procedure. This product is designed and over the nine years of this study.The need for intraabdominal manufactured on the “one piece”principal which means that it reoperation was 52.5%.These long term date fail to support the does not have any mechanical weak point.The operative tech- use of ASGB for surgical treatment of morbid obesity. nique is described in this video.The patient is placed in a modified lithotomy position and reverse trendenburg (35° ). We 85.EARL Y RESULTS WITH THE HELIOGAST BAND. emphasized the positioning of the patient which is the crux point M.Vertruyen. Europe St-Michel Clinic, Brussels, Belgium of the procedure.Initial access to the peritoneum was gained After a bariatric surgery experience of 543 patients using the through a working port.We used a 4 procare technique and 30° LAPBAND system between october 93 and december 2000, the lens.We utilized the pars flaccida approach combined with a author decide to perform a consecutive serie of 30 patients with pars condensa window to minimize risk of slippage. A 15 ml the Heliogast band system between december 2000 and febru- gastric pouch is created.T unelling sutures on the anterior gas- ary 2001. The sex ratio was 26 females for 4 males and the tric wall prevent dislocation of the band and ensure that a pouch mean age was 38 years (range:20-54). The mean body weight of correct size is created.Placement of the catheter and the port was 112 kg (range:93 -145) corresponding to o mean BMI of 44 is discussed. kg/m2 (range:35-56). The author decide to change of banding Results and Conclusions :this laparoscopic technique was system for several reasons:The presence of an easy unlockable successfully completed in all patients even when hepatomegaly. locking system of the Heliogast band.The frequence (2.8 %) of This procedure has not been previously reported.HELIOGAST disruption of the connecting tube of the Lap-Band.The smaller banding (HB) in the short term at least is comparable to other port size of the Heliogast band bands in effectivene ss.HB has wide appeal since its In all the cases, the perigastric way was used and the proxi- demands less time and relative skill. However knowledge of mal pouch was calibrated with 15 cc of saline.A classical ante- subtle details and expertise is required to reproduce favorable rior fixation was performed with 4 sero-serous stiches. At the outcomes of permanent weight reduction and minimal compli- end of the procedure, 2 cc of saline were injected in the system cations. in order to secure the locking system.The mean operative time was 45 minutes (range:30-60). There were no conversions and 87.P ACING THE STOMACH: OUR EXPERIENCE ON TWO no intraoperative complications.The mean hospitalisation stay OBESE PATIENT POPULATIONS. was 1 day (0-2). As early complication, we observed 1 case Cigaina V*., Saggioro A**. *Unit of Digestive Surgical (3.3%) of leakage of the band at the level of the locking system. Electrophysiology O.C. “ Umberto I” Mestre-Venezia, Italy** This area is not reachable during placement of gastro-gastric Digestive Diseases & Clinical Nutrition Departments O.C. sutures. “Umberto I”Hospital Mestre-Venezia, Italy In 3 cases (9.9%), no efficient adjustement of the band was Background:After successful animal studies in 1992, the first possible even with injection of more than 10 cc of saline.A radi- human implant of a gastric pacemaker to modify the gastric ographic study showed the absence of reduction of the stoma environment behavior and treat morbid obesity was performed diameter and confirmed an external distortion of the inflatable in 1995.A cohort of 10 patients started to be followed with long- part of the band.The 4 cases (13.3%) required reoperation and term data collected from 1998.A further group of 10 patients the replacement of the initial band with the second generation were implanted during 2000. Purpose: Evaluate the safety (in of heliogast band (Medium size).All the reoperations were per- terms of reported complications) and effectiveness (in terms of formed by laparoscopy and required an one-day hospitalisation. weight loss) of gastric stimulation in the morbidly obese popula- In a very short follow-up period, the 26 first patients required a tion. mean level of 7 cc (range:6-9). The 4 patients requiring reoper- Methods:20 subjects, between 41 and 69 of BMI, 4 males ation needed a mean of 3 cc (range:2-3). The visual examina- and 16 females, age ranging between 23 to 62 years, were tion of one and the ineffective bands showed the persistence of implanted with a second generation Implantabl e Gastric a aneurysm hernia in the inflatable part of the band.Surgeons Stimulator (IGS™ ), T ranscend ™ , supplied by T ransneuronix need technical advise about the soundness of a new device and Inc., New Jersey , USA. 13 of these subjects received a new security about the quality control of the materials used before pacer as a replacement for a previous device.The pacer was application of the new device.This serie is too small to give a placed in the subcutaneous abdominal fat over the muscular definitive conclusions but Helioscopie needs to solve as quickly fascia and connected to a bipolar lead, which was placed under as possible the problems of size of the band, weakness and general anesthesia and by video-laparoscopy, in the lesser cur- external distortion of the inflatable part. vature of the gastric antral wall.The pacer was activated thirty days after the implant.The patients were discouraged to drink 86.LAPAROSCOPIC EXPERIENCE WITH A NEW alcohol and sweet beverages. Monthly clinical controls were ADJUSTABLE GASTRIC BAND. obtained for the first 6 months period, and every three months Patrice Lointier, MD , PhD. Private Practice, Clermont-Ferrand, thereafter. France. Results:The first patient, of 1995 trial, lost 90% of her excess Background:the purpose of this study is to present a prelim- body mass at 21 months after the implant.After pacer replace- inary laparoscopic experience with a new adjustable silicone ment she reached 60-70% of Excess Body Mass Loss (EBL) band named HELIOGAST. and maintained it till the 52nd month, when she had lead dis- Methods:since october 2000, 70 morbidly obese patients lodgment.The results of all the patients, before having the first having body mass index (BMI) > 35kg/ m2 underwent HELIO- pacer replacement, three months after, and the group implanted GAST laparoscopic procedure.The product used possesses an during the 2000 are shown in the following table: opening and closing system. In the event of a AgeWeight BMI EBMI %EBL %EBL %EBL %EBL complication, the ring does not need to be cut and replaced by (kg) 3m 6m 9m 12m

402 Obesity Surgery,11, 2001 Crete Abstracts

98 4M-6F assess the results with regard to weight-loss.The IGS could be Mean34.8 142.2 47.9 22.9 15.9 19.1 23.2 24.4 also an interesting second-step procedure in treating failures of Std.Dev8.6 23.7 5.8 5.8 9.9 11.8 9.6 11.5 restrictive procedures. 98 re-impl Mean 130.443.5 18.5 18.9 23.7 20.6 89.SUCCESSFUL USE OF ENDOSCOPIC ULTRASOUND Std.Dev 22.46.0 6.1 12.5 12.5 11.9 (EU) TO VERIFY LEAD PLACEMENT FOR THE 2000 10F IMPLANTABLE GASTRIC STIMULATOR (IGS™). Mean42.3 132.2 51.5 26.5 17.4 27.4 40.5 49.2 Scott A. Shikora, MD , Tamsin A. Knox, MD, Laurence Bailen, Std.Dev11.8 33.1 9.1 9.3 4.8 9.5 15.0 26.3 MD, Frederick J. Doherty, MD, Christa M. Trigilio, P A-C. New There have been no deaths or other major complications.The England Medical Center, Boston, MA, USA main feeling reported from all the patient population during the Background:Gastric stimulation is a promising new modality gastric pacing was an early and increased satiety, which rein- for achieving weight loss. The IGS, a pacemaker-like device forced the patients’efforts for food intake reduction.Despite the (TranscendTM, manufactur ed by T ransneuronix, Inc, Mt. electrical stimulation of the stomach, no peptic related disorders Arlington, NJ), had been shown to be safe and effective for ini- or gastrointestinal side effects were reported. GERD was tiating and maintaining weight loss in a small pilot study by improved after stimulation. There have been 6 intra-operative Cigaina et al (Obesity Surgery 1999).Currently , it is undergoing gastric penetrations, as noted on operative gastroscopy without evaluation in both Europe and in the U.S. Lead dislodgment any clinical sequellae.Of the 13 replacements, six had lead dis- from the stomach wall has occurred in 25% of patients in the lodgments (two partial, four total), which occurred between the first half of these trials prior to changes in technique.Complete first and fourth months. This was probably due to inadequate dislodgment (CD) can usually be diagnosed by patient symp- tine length on the leads.Subsequently , after those events, all toms and/or by radiographs.However, some CD and most par- leads were fixed using sutures and only one partial dislocation tial dislodgments (PD) may not be diagnosed non-invasively was reported. and may impact weight loss if one or both electrodes are dis- Conclusions :Long-term studies continue to show that gastric lodged.At present, only laparoscopy can be used to determine pacing can be a safe and effective procedure. A metabolic lead status. This investigation analyzed whether EU may be change or a new standpoint in the brain-gut axis is hypothe- successful as a less invasive diagnostic tool for assessing lead sized, and studies regarding mechanisms of weight loss due to location. gastric pacing are progressing. Methods:A porcine model was first used to determine 4 main goals:1. To assess whether the lead could be visualized.2. To 88.IMPLANTABLE GASTRIC STIMULATION:PRELIMI- determine whether the electrodes could be identified 3. T o NARY RESULTS IN FRANCE. locate the electrodes both within the stomach wall and outside Jerome Dargent, MD. Polyclinique de Rillieux. Private practice, it.4. To determine which layer of the stomach wall the electrodes France resided.A lead was placed in an intact en vitro porcine stomach. Background:A new technique has been added to bariatric Three positions were chosen:Both electrodes within the stom- surgery:the Implantable Gastric Stimulation (IGSTM), which ach wall, one outside the stomach wall, both outside the stom- seems to be able to induce satiety while avoiding the drawbacks ach wall.An Olympus radial echoendoscope (UM-20) was used of malabsorptive or restrictive techniques.An experimental pro- for all studies at a 12MHz frequency.EU was performed for each tocol was initiated by Transneuronix Inc., Mt.Arlington, NJ, USA, on the basis of Dr V Cigaina’s works, consisting of clinical trials position.After this, a study patient with a presumed PD based launched in Europe and in the US at the beginning of year 2000. on poor weight loss and rising lead impedance was scheduled After approval by the ethics committee, the French centre of for lead replacement. Just prior to laparoscopy , EU was per- experimentation was located in Lyon. formed. Methods:The device (TranscendTM) consists of a stimulation Results:In the en vitro porcine model, EU successfully lead implanted in the gastric wall and connected to an electric imaged stomach wall layers, identified both electrodes within pulse generator implanted subcutaneously. The procedure is the lead and could determine whether or not the electrodes performed through laparoscopy, using a wall suspensor. The were in the wall of the stomach.In the patient, EU traced the possibility of a gastric perforation is checked during an intra- lead along its course from outside the stomach wall to inside it. operative endoscopy .The authors present the surgical tech- It also identified the proximal electrode within the wall of the nique and preliminary results obtained in France in 12 patients stomach.This was then confirmed by laparoscopy. (5M, 7F) operated between July 2000 and February 2001.Mean Conclusion:This preliminary report suggests that EU may be age was 40,6 (31-51). Mean weight was 122.2 kg (93-146), a useful, less invasive procedure for assessing lead location mean BMI was 42.7 (39.1-48.6), and mean excess-weight 60 kg when there is a question of dislodgment and the standard radi- (42-74).5 patients had comorbidities. 6 patients had the lead ographs are non diagnostic. implanted in a low position, six in a high position.The experi- ment was not randomised.Patients enrolled at the French site 90.GASTRIC PACING VERSUS GASTRIC BANDING IN were also programmed to “high”output settings (10 mA pulse MORBID OBESITY – THE MAGDEBURG EXPERIENCE. amplitude) at one month-visit.Patients were seen monthly post- S.Wolff, C. Gerards*, H. Lippert, P .Malfertheiner*. Dept. implant. Surgery, Dept. Gastroenterology*, University of Magdeburg, Results:Postoperative course was uneventful in all cases.In Germany 2 patients, the lead was replaced because of dislodgement. Background:Gastric banding is used in many European cen- At 6 months, mean excess weight-loss has been 8.5 kg (0-32) ters in surgical treatment morbid obesity .Gastric pacing is a or 15% (0-51) of the excess-weight at the implant time. new surgical technology currently under investigation.The aim Conclusion:The surgical procedure has to be standardized of this study is to validate the effect of gastric pacing on weight furthermore.A long-term follow-up will be needed in order to loss in comparison to gastric banding.

Obesity Surgery,11, 2001 403 Crete Abstracts

Methods:Patients are randomised to 3 treatment arms for it deliberately for the SAGB in a virgin plan of dissection. patients with a BMI > 40, fulfilling WHO criteria for Bariatric Surgery:a) n=10, gastric banding (validated method), b) n=10, 92.SWEDISH ADJUSTABLE GASTRIC BAND: PRINCI- gastric pacing, switched on, c) n=10, gastric pacing, switched PLES OF AN OPTIMAL BAND ADJUSTEMENT. off (placebo).Changes in weight, eating behavior and life qual- Hans Triaca-Bernasconi, MD;Guido Stirnimann, MD;Christian ity are evaluated before and 6 months after operation.Non-inva- Klaiber, MD. Hospital of Aarberg,Switzerland sive follow-up is repeated monthly.Complete re-examination is Background:The postoperative follow-up of patients with done after 6 months. SAGB is of great importance in order to obtain good results. Results:Twelve patients have been enrolled (10 female, 2 Correct fillings and permanent adjustment of the band,adapted male, mean age 32 years, mean BMI 43,1 kg/ m 2).So far, 8 to each patient,are of essential importance.Restriction is a main patients were implanted with a gastric pacemaker.Intra-opera- factor for losing weight and determines to a great extent the tively, no major complications are to be reported.On the long quality of life of the patients. term, no deaths or major surgical complications have been Methods:From August 1996 to August 1997 the first group of seen.2 lead dislodgments (prior to improved fixation) and 1 23 patients was operated at the Aarberg Hospital.The surgeon chronic gastric wall penetration required re-operation. In the carried out the follow-ups.The second group of 40 patients was patients that have completed 6 months follow-up, weight loss operated between August 1997 and December 1998 and was was between 5 and 23 kg. followed-up postoperatively by an interdisciplinary team. We Conclusions :These preliminary data suggest a new way for compared the two groups with regard to loss of weight and band inducing weight loss in morbid obesity through a surgically safe fillings 12 months after the operation. and feasible laparoscopic procedure.Improvements in the nee- Results:Both groups were comparable in terms of age,sex dle of the pacing lead and in fixation of the electrodes will be and BMI.The interdisciplinary care included necessary prior to widespread use. a change in the band filling procedure.Both groups received their first filling of 3-4 ml Jopamiro 4 weeks postoperative 91.COMP ARATIVE STUDY BETWEEN LAP-BAND AND (po.).The first group was then given a few fillings with 1-3 ml SWEDISH ADJUSTABLE GASTRIC BANDING. each filling.Average BMI preoperative (preaop.) 47,02 average J.M.Fabre, D. Nocca, M.C. Lemoine, C. Vacher, C. de Seguin, BMI 12 month po.35,15 average band filling 12 months po 6,67 E.Renard, J.Domergue. Hôpital Saint Eloi, Montpellier ml.The interdisciplinary group received more frequent fillings, of Background:From September 1996 to March 2001, 476 0,5-1 ml each.Average BMI preop. 47,89 average BMI 12 patients were operated under laparoscopy for severe obesity . months po.36,96 average band filling 12 months po 4,78 ml. We compared the results of the 119 Lap-Band (placed between Conclusion:A continuous interdisciplinary patient care with 96 and 99) to the 110 SAGB (placed in 99) to have an average more frequent,but smaller band fillings allows to reach an follow-up of at least 18 months on the latter. almost equal loss of weight,with less filling amount.This means Methods:All the patients were operated on by three senior more quality of life, especially with regard to the frequency of surgeons (JD, CdG, JMF) after a multidisciplinary evaluation vomiting and a well balanced-diet. (endocrinologist, dietician, psychologist). Mean age of the patients (39 years), mean preoperative body mass index 93.A COMPARISON OF COMPLICA TION RA TES IN 151 (44.5Kg/m2), and sex ratio (86% of female) were comparable CASES OF LAP-BANDING AND 174 CASES OF THE between groups. Conversion rate was 1% (n=5), occurring in SWEDISH ADJUSTABLE GASTRIC BAND. the beginning of our experience, because of gastric injuries (2 James D. Ritchie, MD. Keyhole Surgery Centre, Sydney , cases), liver hypertrophy (2 cases) and liver bleeding (1 case). Australia Operative mortality was nil.In spite of the systematic anticoag- I began to use the Swedish band at the end of 1998.My rea- ulant treatment, we had a pulmonary embolism with favourable sons for changing devices was the high rate of revisional outcome.Mean hospital stay was 4 days in each group. surgery I experienced with the Lap Band.29% of my Lap Results:80% and 70% of the patients were followed to 12 Banding patients required revision with reposition ing or and 18 months.At one year mean excess weigh loss was 51% removal.I believe the cause for this was the placement of the and BMI was decreased by 10, whatever the groups. band across the posterior wall of the stomach high in the lesser Complications rate was significantly higher with the lap-band sac below the pars flaccida.The tendency to slip was also than with SAGB: pouch dilation 9% (n=11) versus 2% (n=2), aggravated by the smooth hard nature of the device.This allows slippage 23% (n=27) versus 2% (n=1). These slippages were for early displacement and in time this develops into a full scale treated by repositioning of the lap-band under laparoscopy 12 slippage with obstruction.The band itself does not adhere to the times, by change towards a SAGB under laparoscopy 10 times stomach but encapsulates leaving an opening through which or towards a vertical banded gastroplasty 1 time, by removal of the the stomach can prolapse especially when the band is the band 5 times.Five patients had a second slippage, which deflated. has occurred 4 times after a first repositioning of the lap-band. I found the constant presentation of obstructed dehydrated Finally, 8 Lap-band were removed (7%) and only one in group patients requiring urgent I.V.therapy and surgical correction to SAGB due to a leakage of the balloon.T o date We do not have be such a burden that I resolved to change devices.Most reports any case of gastric erosion with Lap-band or the SAGB about the Swedish band indicated that it had a very low slippage Conclusion: the choice of the material must take account of rate so I resolved to change to this device.The low incidence of the frequency of the complications for each band.If the majority slippage is due to placement of the band through the pars flac- of them occur in the first two postoperative years, the real risk in cida thus providing secure posterior fixation.A further factor may the long-term is possibly underestimated.We stopped the use be the low pressure balloon which deforms around the stomach of Lap-band because of the high rate of the slippages.Our cur- and which may grip it gently making it less prone to early slip- rent attitude in the event of slippage on Lap-band is to change page.

404 Obesity Surgery,11, 2001 Crete Abstracts

My experience to date with the SAGB indicates weight losses tion.Of these patients, 70 with a BMI > 50 (average age 37.4 comparable to the Lap Band.Complications are one greater cur- years, average weight 150.8 kg, average BMI 55.8) underwent vature slip,one erosion,two avulsions of tubing from the injection biliopancreatic diversion with Roux-en-Y gastric bypass (gastric port,one perforated tube and two displacements of the port into pouch 15± 5ml, alimentary limb 350cm with common limb the abdominal cavity giving a total complication rate over two 100cm).Cholecystectomy and appendectomy were also per- years of 4%.The device itself is soft and more easily damaged formed at the time of surgery provided these procedures had than the Lap Band.Great care must be taken to avoid rough not been performed at an earlier date.All patients were seen at handling and needle puncture.I have damaged 4 bands.The 1, 3, 6, 9, 12, 18 and 24 months postoperatively and yearly damage was recognised at the time and the bands replaced.All thereafter.Average follow-up time to date is 18.8 months or 1.6 bands should be tested for leaks before placement and at the years (2-55 mos.) and follow-up is 100%. A multivitamin and end of the procedure so as to minimize the chance of a leaking mineral supplement and 2 gr. calcium are prescribed for all band being left in situ. patients daily as well as 80 mg iron in premenopausal women. Radiology examination is performed in all patients on the 4th 94.REDUCTION OF OBESITY-RELATED CO-MORBIDITY postoperative day and at each yearly visit in order to check for AFTER LAPAROSCOPIC GASTRIC BANDING (SAGB ®). staple-line disruption. A. Glättli1,3 G.Stirnemann 2, S. Schlatter 1, R. Stouthandel 1, H. Results:Early postoperative morbidity (£ 30 days) was Triaca2, Ch. Klaiber 2. Zieglerspital Bern 1, Spital Aarberg 2, 12.85%.Late postoperative morbidity (>30 days) was 17.1%. Salem-Spital Bern 3, Switzerland There was no early or late mortality. Weight loss results Background:Laparoscopic implantation of an adjustable gas- expressed as average % excess weight loss (EWL) are as fol- tric band has in Europe become a standard treatment of morbid lows:56.2% (29-84%) at 1 year (38 patients), 58.5% (34-78%) obesity.The aim of the operation is not only weight loss but also at 2 years (21 patients) and 52.2% (28-91%) 3 years following reduction of obesity-related co-morbidity.We studied the results surgery (11 patients).Further separation of weight loss results in our patients with respect to the metabolic syndrome by sex showed that EWL was significantly higher in males at all (Diabetes mellitus, Dyslipidemia, Hyperuricemia,Hypertension). time periods. Nutritional complications included one case of Methods:From 8.1996 to 9.2000 we operated on 310 hypoalbuminemia (1.4%) in a female patient 20 months follow- patients (M:W = 61:249; median age: 38.3 (18-64) years) by ing surgery , which was easily corrected by administration of implantation of a Swedish Adjustable Gastric Band (SAGB ®). TPN and subsequent increase in dietary protein intake.Other BMI:44.6 (34-65) kg/m 2, overweight:54 (22-116) kg.The meta- nutritional complications included anemia (27.7% at 1 year, bolic syndrome was defined by measuring the following para- 37.5% at 2 years and 33.3% at 3 years), iron deficiency (18.7% meters:Diabetes mellitus (HbA1c), Dyslipide mie at 1 year, 25% at 2 years and 55.5% at 3 years) and vitamin B12 (Cholesterol/HDL-C), Hyperuricemie (uric acid), Hypertension deficiency (27.7%, 31.2% and 44.4%, respectively), both of (systolic and diastolic blood pressure).Only patients were eval- which were treated with extra supplementation. There was no uated with a follow up of 3 months and more. clinical symptomatology, and no hospitalization for these defi- Results:Median operating time was 90 (30-235) min., con- ciencies was necessary.Evaluation by BAROS for all patients version rate was 0.97%. Morbidity within 30 days was 1.61%, with at least 6 months follow-up was unsatisfactory in one late morbidity occurred in 13.2% of all patients. No mortality . patient (1.63%), fair in 4 patients (6.5%), good in 20 patients After a mean follow up time of 24 (3-48) months 47.3% of (32.7%), very good in 25 patients (40.9%) and excellent in 11 patients lost 50 % or more of their overweight.Reduction of co- patients (18%).Finally , we found significant improvement or res- morbidity is shown in the figure below (numbers are % patho- olution of all preexisting comorbidities. Most notably , sleep logical values).Months 0 6 12 18 24 36 Patients 310 247 206 apnea, hypoventilation syndrome and dyslipidemias were com- 93 133 35 HbA1C 23.7 16.6 13.7 6.1 10.6 6.9 Chol/HDL-C 31.0 pletely resolved within the first month following surgery. 19.3 12.2 4.6 5.2 2.1 Uric acid 50.6 40.3 28.6 32.3 23.5 17.2 Conclusion:BPD with RYGBP appears to be a safe and Systolic 30.0 32.6 31.7 33.3 24.0 25.0 Diastolic 25.1 21.3 11.5 effective bariatric procedure for the super-obese patient. 27.8 12.0 20.8 Diabetes mellitus, Dyslipide mie und Hyperurikemie was eliminated or improved in a significant way 96.LONG-TERM RESULTS OF BILIOPANCREATIC DIVER- within time and Hypertension showed a tendency towards SION IN SUBJECTS WITH PRADER-WILLI SYNDROME. improvement. Francesco Papadia, Giuseppe M.Marinari, Giovanni Camerini, Conclusion:Laparoscopic gastric banding has a positive and Federica Murelli, Paola Marini, Cesare Stabilini, Flavia Carlini, significant effect on the metabolic syndrome and gives besides Nicola Scopinaro. DICMI, Semeiotica Chirurgica R, University weight loss an amelioration of patients health. of Genoa School of Medicine, Genoa, Italy Background:The Prader-Willi Syndrome (PWS) is a congen- 95.BILIOPANCREATIC DIVERSION WITH ROUX-EN-Y ital disorder characterized by neonatal hypotonia, short stature, GASTRIC BYPASS (BPD WITH RYGBP) FOR THE SUPER hypogonadism, mental retardation and compulsive hyperpha- OBESE: PRELIMINARY RESULTS. gia, with the development of early obesity.Since gastric restric- Mead Nancy, Skroubis George, Kritikos Neoklis, Soulikia Klea, tive surgery requires strong patient’ s compliance to achieve Loukidi Aggeliki, Kalfarentzos Fotis. Nutrition Support and weight loss results, this approach has failed in fighting PWS Morbid Obesity Clinic, Surgical Department, University Hospital patients’obesity , whilst the malabsorptive approach seems the of Patras, Greece most appropriate one. Background:Super obese patients who undergo purely Methods.15 (9 M) patients with PWS were submitted to BPD restrictive bariatric procedures or standard gastric bypass oper- between June 1986 and February 1996.In all cases PWS diag- ations often fail to maintain satisfactory long-term results. nosis, made at a mean age of 6.5 yr.(6 mo-14yr), was done in Methods:From June 1994 to April 2001, 196 morbidly obese children’s hospital.According to Holm’s criteria, at the time of patients underwent various bariatric procedures at our institu- the operation all of the subjects had a total score of 8 or more.

Obesity Surgery,11, 2001 405 Crete Abstracts

Preoperative mean age was 21 (12-31) yr., mean weight 127 requesting the procedure as their preferred option for bariatric (84-164) kg, mean excess weight 74 (34-116) kg, correspond- surgery as they perceive it to be more reliable and to be less ing to mean 142 (67-237) % of the ideal, mean BMI 53 (36-72), restrictive than banding.I feel it is particularly suitable for males mean waist/hip 0.97 (no differences between M and F).At the the superobese the diabetics those who have hyperlipidemia time of operation 4 subjects had hypercholesterolemia, 3 had those who are sweet eaters those who suffer from reflux type II diabetes mellitus and 4 had hypertension.Indication to oesophagitis. BPD was BMI >40 and, in 3 cases, >35 with concurrent meta- Results:Follow up,however, indicates significant incidences bolic complications.Mean follow-up is 8.5 (4-13) yr.W.A.I.S. T est of deficiencies of fat soluble vitamins The following incidences for I.Q.assessment was performed at a recent visit in each sub- of deficiencies have been documented Vit A 10%, Vit D 12%, Vit ject, with a mean score of 72 (56-84).An arbitrary score based K 6% Iron 14.6%, Calcium 1.5%, Protein 2%. The exact inci- on lifestyle was given to each subject:1 (at home with parents, dence of the deficiencies is under review at present and total inaction and near absence of interest in life);2 (at home updated data should be available for presentat ion at participating in housework, irregular attendance at specific ref- IFSO.There is a sizeable incidence of stomal ulceration (3%) erence center);3 (regular job and /or regular attendance at spe- and of incisional herniae (3.5%).Results and other complica- cific center). tions are presented. Results:No perioperative complications were observed. Conclusion:Biliopancreatic diversion is one of the most effec- Mean body weight showed a percent loss of the initial excess tive procedures available to control morbid obesity.Patients who (IEW%L) of 59±15 at 2 yr.and of 56±16 at 3 yr., and then a pro- undergo this surgery,however must commit to remaining under gressive regain: at 5 yr.the IEW%L was 46± 22 and at 10 yr. surveillance as they are at risk from the side effects of malab- 40±27, with marked interindividual differences among the oper- sorption.They must take vitamin and mineral supplements in ated patients.Actually, according to BAROS criteria for weight large amounts to offset the loss of vitsA,D,E & K, calcium and loss, of the 14 subjects at 5 yr., 8 (57%) had excellent or good iron.At present my preferred supplement is Vita4Life.They must result (IEW%L ³ 50), 3 (21%) fair result (IEW%L between 25 eat 100gms of good quality protein and avoid fats in their and 49), and 3 (21%) were failures (%EWL £ 24);of the 7 sub- diet.They must have 6 monthly biochemistry to detect and treat jects with a 10-year follow up, 3 had good result, 1 fair result and any developing deficiencies.Aggressive techniques such as 3 were failures (1 died during his 9th postoperative year). TPN or iron infusion are at times required to maintain normal Spearman rank test did not demonstrate any correlation biochemistry. between weight loss at 5 yr. and preoperative age, initial per cent excess weight, preoperative BMI, preoperative waist/ hip 98.OUR BARIATRIC SURGERY EXPERIENCE WITH BILIO- ratio, waist circumference alone, age at diagnosis, and IQ score, INTESTINAL BYPASS. while a correlation was found (Spearman r= 0.8548, p <.0001) Bressani Doldi Santo, Micheletto G., Perrini M. Cattedra di between weight loss at 5 yr.and lifestyle score.Both type II dia- Chirurgia Generale dell’Università degli Studi di Milano - Istituto betes mellitus and hypercholesterolemia disappeared already 1 Clinico Sant’Ambrogio (Direttore:Prof. S.B.Doldi); Centro per la month after surgery with no relapse during the whole follow-up Farcomacoterapia delle Malattie Nutrizionali e Metaboliche “E. period, even in patients who failed weight control.Hypertension Genovese e R. Klinger”(Direttore Scientifico: Prof.S.B.Doldi) was cured in all the 4 affected patients within the 1st postoper- Background: Since 1974 we have performed these bariatric ative year.1 patient had recurrent protein malnutrition and 24 operations : 312 jejuno-ileal bypass (JIBP); 80 bilio-intestinal months after BPD underwent surgical revision with elongation of bypass (BIBP);102 horizontal gastroplasty;44 silastic ring ver- the common limb, 2 subjects had an incisional hernia, 1 devel- tical gastroplasty; 325 adjustable gastric banding (262 Lap- oped severe bone demineralization;1 of the unsuccessful sub- band®) and 240 intragastric balloons (BIB ®).After 1979 when jects died on the ninth postoperative year from respiratory fail- D.Hallberg popularized bilio-intestinal bypass, approximately for ure, while another subject with very good weight loss result died a decade we used this procedure only in morbidly obese on the 6th year from causes unrelated to either obesity or BPD. patients with previous hepatic diseases.Since 1990, we have Conclusion:Though in PWS patients a full recovery from obe- adopted definitively bilio-intestinal bypass for all cases that sity cannot be achieved with any known treatment, BPD has to could be appropriately treated with malabsoptive procedure. be considered for its value in prolonging and qualitatively Methods: 80 patients (Male:36; Female: 44); mean age 35.2 improving the patient’ s life, since it provides the best known ±8.3 years; preoperative mean weight Kg 152.3 ± 22.8;BMI weight loss results. 53.8 ±5;mean follow-up 8 years.The decision to resort to BIBP was adopted by a multidisciplinary team.On discharge patients 97.BILIOPANCREATIC DIVERSION,POSTOPERATIVE were subjected to a multivitamin and multielectrolyte therapy, to MANAGEMENT CHALLENGES, EXPERIENCE WITH 198 antidiarrhoea drugs when necessary and monthly check-up dur- CASES OVER 7 YEARS. ing the period of weight loss (18-24 months). The indications James D Ritchie, MD. Keyhole Surgery Centre,187 Macquarie and contraindications we have followed were the same adopted St, Sydney, Australia at NIH conference (1991). Background:My experience with biliopancreatic diversion Results: Two years post-operatively 38,7% of initial weight began 7 years ago.I was looking for a procedure to offer patients had been lost by 91.2% of the patients, with the reduction of the who had failed with restrictive procedures such as banding or excess weight of 78.2% and in BMI of 37.7%.The weight reduc- stapling.Many of my early patients had had a number of such tion was stable.Insufficient weight loss (<20% initial weight) was procedures.Following a visit to Prof Scopinaro’s unit in 1993 I 5%.The most important early and late complications were: commenced my experience with biliopancreatic diversion. severe diarrhoea with electrolytes unbalance (1.2%), abdominal Methods:The early results proved so successful that I have bloating (6.2%) and incisional hernias (11.2%).The reversal and continued to offer this procedure to patients who have failed conversion rate was 5% and death rate 0%. No one of our restrictive procedures or who are superobese.Many patients are patients had liver failure or interstitial oxalic nephritis.

406 Obesity Surgery,11, 2001 Crete Abstracts

Conclusion: In comparison with JIBP , the bilio-intestinal C. Vassallo, M. Andreoli, G. Berbiglia, A. Pessina, D .Savioni bypass produces a satisfactory weight loss in more patients Private Practice, “Morelli”Clinic, Pavia, Italy (91% vs. 83%) with less early and late complications and no Background:We started to perform bariatric surgery in 1978. mortality . Moreover, the less severe diarrhoea provides an Since then until today we have used 4 different malabsorptive important clinical advantage and improvement in the quality of techniques in all on 235 superobese patients, on a total of 1242 life.By our experience we can state that the BIBP still has an patients operated.Aim of this review is to try and standardize important role in bariatric surgery, above all in morbidly obese the reasons to choose between the various malabsorptive tech- young patients with BMI > 50, for patients refusing drastic long- niques, independently from their evolution in time, as these term food intake restriction, for patients with compulsive bulimia techniques are still used. and following unsuccessfull gastric restrictive surgery.At last we Methods:This review concerns 21 intestinal bypasses, 128 want to emphasize that BIBP is completely reversible and less “Doc”B.P .D.s, 82 T .G.R./D.S./B.P.D.s* and some gastric aggressive than the other malabsorption procedures. Quite bypasses in the last three months. All these techniques have recently we performed bilio-intestinal bypass by laparoscopic been our first choice, except 11 T.G.R./D.S./B.P.D.s, which were technique:that is of great benefit for the patients (less pain, performed to correct gastric restrictive surgery. shorter stay in hospital, less cardiorespiratory and thromboem- Results:The basal BMIs of the 4 groups of patients were sim- bolic complications, better aesthetic result) and for the commu- ilar.The average excess body weight in the cases with a 5 years nity (less costs). follow-up was equal to 29%.The effectiveness on dysmetabolic syndromes and the percentage of complications are different 99.INTESTINAL OBSTRUCTION AFTER MALABSORP- and it is just on this basis that we can elaborate some choosing TIVE PROCEDURES: STILL A POTENTIALLY DEADLY COM- principles. PLICATION. Conclusions :The “Doc”B.P .D.technique is particularly effec- Kenneth B. Jones, Jr, MD. CHRISTUS Schumpert Health tive for the treatment of dysmetabolic syndromes; its gastric System preservation variant is quite fit to treat gastric restrictive surgery Background:With the recent surge in interest in bariatric failures.The intestinal bypass is more easily and quickly per- surgery, particula rly with laparoscop ic Roux-en-Y gastric formed, but has some drawbacks in the short and medium bypass, although infrequent, intestinal obstruction is and will be period. seen more often as our patient population mushrooms.At the expense of traditional bariatric surgery principles in favor of 101.FLEXIBLE ENDOSCOPY IN THE MANAGEMENT OF expediency, we frequently cut corners to achieve our goals PATIENTS UNDERGOING ROUX-EN-Y GASTRIC BYPASS. laparoscopically, lulling ourselves into a sense of complacency, Bruce Schirmer, M.D ., Anna Miller, R.N. University of Virginia while increasing the risk of small bowel obstruction at or distal Health Sciences Center, Charlottesville, VA, U.S.A. to the entero-enterostomy. Background:Flexible upper endoscopy (FUE) is an important Methods:Over a 15 year period from 1986 to May of 2001, in diagnostic and therapeutic tool in the management of upper 1,996 primary and conversion RYGBP’s, there were 15 gastrointestinal diseases.We examined the role of FUE in the instances of subacute and acute small bowel obstruction, prin- management of patients undergoing Roux-en-Y gastric bypass cipally at the entero-enterostomy.This can lead to acute gastric (RYGP). dilatation, as the biliopancreatic limb is obstructed with subse- Methods:All patients undergoing RYGB by a single surgeon quent ischemia and pressure necrosis, a potentially deadly at a single institution from 1986 to 2001 were studied. problem.Physical signs and symptoms include sustained tachy- Preoperative FUE was performed by the surgeon on an outpa- cardia, oliguria, hypotension and biliary regurgitation and vomit- tient basis to assess the anatomy of the esophagus, stomach, ing.Frequently a palpable epigastric mass is noted.Laboratory and duodenum.Since 1997, gastric biopsies were obtained dur- data is inconsistent, but bilirubin and amylase may be elevated ing FUE for either histology or CLO testing for the presence of due to the back pressure thus produced.Emergency radiologic H.pylori.Colonized patients were treated preoperatively with examination is imperative.However, the standard acute abdom- triple therapy.Postoperatively, FUE was performed by the sur- inal series frequently looks unremarkable, and upper GI series geon as indicated clinically for management of symptoms sug- may not help if the alimentary and common limb are not gesting anastomotic stenosis, upper gastrointestinal bleeding, obstructed.Abdominal ultrasound is usually helpful, but CT of inflammation, or ulcers.Endoscopic balloon dilatation was per- the abdomen is always diagnostic of the massively dilated, usu- formed as indicated using a size 18-20 Fr.balloon. Patient and ally gasless bypassed distal stomach and proximal small bowel. procedure data were recorded in a database.Statistical analy- Results:In the cases presented, diagnoses included internal sis was performed using Chi square analysis. hernia, adhesions, retrograde intussusception at the entero- Results:A total of 560 patients underwent RYGB during the enterostomy, cecal volvulus, and a spontaneous hematoma of study period. Of these, 536 underwent preoperative FUE. the small bowel wall. Endoscopic findings changed or altered the operative proce- Conclusion:Many bariatric surgeons are alone in their com- dure in 26 patients (4.9%).Preoperative testing for H.pylori was munities.Therefore, they need to make their non-bariatric performed for 206 patients, of whom 62 (30.1%) were positive. surgery colleagues, medical, surgical, and primary care aware Patients tested for H.pylori had a lower incidence of postopera- of these potentially deadly problems and the diagnostic tools to tive marginal ulcers (n=5, 2.4%) than did patients who did not aid in their solution. undergo such screening (n=24 of 354, 6.8%, p<0.04). Postoperatively, 60 patients underwent 87 endoscopic balloon 100.MALABSORPTIVE SURGERY IN THE THERAPY OF dilatations for stenosis of the gastrojejunostomy.In addition,46 SUPEROBESITY: REASONS TO CHOOSE BETWEEN THE patients underwent 58 FUEs that proved negative for such “DOC”B.P .D TECHNIQUE AND ITS V ARIANTS, GASTRIC stenosis.A total of 69 patients underwent 93 additional diag- BYPASS AND INTESTINAL BYPASS. nostic or therapeutic FUEs by the surgeon in the postoperative

Obesity Surgery,11, 2001 407 Crete Abstracts period, including investigation of symptoms of pain, bleeding, MD FACS. Center for Surgical Treatment of Obesity , T ri-City persistent vomiting, or weight regain. Regional Medical Center, Hawaiian Gardens, USA Conclusion:Flexible upper endoscopy (FUE) is a tool which Background:Morbid Obesity is one of the major risk factors may be used by the surgeon in the preoperative and postoper- for gallbladder disease, and this risk is even greater following ative management of patients undergoing RYGB to modify ther- rapid weight loss.Because of this, prophylactic cholecystectomy apy, improve outcomes, and diagnose and treat postoperative is offered to patients undergoing the Transected Silastic Ring complications. Vertical Gastric Bypass ( Fobi Pouch Operation) at the Center for Surgical Treatment of Obesity .A study was undertaken to 102.OBJECTIVE ASSESSMENT OF THE EFFECT OF determine the incidence of pathologic gallbladders in patients LAPAROSCOPIC GASTRIC BYPASS ON ESOPHAGEAL pH undergoing prophylactic cholecystectomy AND MOTILITY IN MORBIDL Y OBESE PATIENTS WITH Method:The records of all patients who underwent the Fobi GERD. Pouch surgery from June 1999 to Nov.2000 were reviewed. Emma J.Patterson MD, Yashodhan S.Khajanchee MBBS MS, Pathologic findings of the gallbladder were documented as Lee L. Swanstrom MD. Legacy Health System, Portland, cholelithiasis, cholecystitis, cholesterolosis, polyps, carcinomas Oregon, USA or normal. Background:Gastroesophageal reflux disease (GERD) is Results:761 patients had the Fobi Pouch.178 (23%) patients prevalent among morbidly obese patients. Although bariatric had cholecystectomy prior to the surgery.154 (20%) had gall- surgery often improves reflux symptoms, the objective effects of stones documented by ultrasound and had cholecystectomy at bariatric surgery on esophageal physiology and pathologic the time of the surgery .286 of the 429 patients with negative GERD are less well documented.The aim of this study was to preoperative findings by ultrasound had pathologic evidence of analyze the effect of gastric bypass surgery on esophageal gallbladder disease. motility and acid reflux, since it is possible that asymptomatic Conclusion:The incidence of gallbladder disease with nega- acid reflux may occur even with a small (15 ml) gastric pouch, tive preoperative findings is high enough in morbidly obese or that a small pouch may exacerbate esophageal motility dis- patients (67%) to warrant routine cholecystectomy at the time of orders. weight loss operation. Methods:In our minimally invasive bariatric surgery program, morbidly obese patients with reflux symptoms routinely undergo 104.INITIAL EXPERIENCE WITH OPEN AND LAPARO- esophageal manometry and 24-hour ambulatory pH studies SCOPIC GASTRIC BYPASS IN NAPLES prior to laparoscopic Roux-en-Y gastric bypass surgery.These Luigi Angrisani, Vincenzo Borrelli, Michele Maresca, Michele objective tests of esophageal physiology are repeated one year Lorenzo, Gaetano Cimmino, Monica Ciannella, Monica Giuffrè, postoperatively. Annalicia Mozzillo. Unit of Endoscopic Surgery, “ S.Giovanni Results:Six female patients with a mean age of 40 years Bosco”Hospital, Naples, Italy (range 19-61) have completed the protocol, at a mean of 13.8 Background:The use of Open (RYGBP) and Laparoscopic months post-operatively (range 11-15).Five of six patients had Roux-en-Y Gastric Bypass (LRYGBP) for the treatment of mor- normal preoperative motility , and all of these patients experi- bid obesity has been limited in Italy.This is a report of the early enced complete resolution of reflux symptoms and a drop of results obtained with Gastric Bypass performed via laparotomy DeMeester score to normal levels.The other patient had a spas- and laparoscopy in a single centre with previous and current tic esophagus preoperatively , which improved somewhat after experience in Lap Band System ® procedures (LASGB ®). surgery.Her reflux symptoms improved but did not completely Methods:From January 2000 to April 2001, 62 patients resolve, and her DeMeester score increased from 9 to 18 after referred for surgery were selected according to the following cri- surgery.Data means are presented in the table below, with teria:LASGB ® in highly motivated patients with BMI < 50, results of paired t-tests. LRYGBP in those without compliance for LASGB and BMI £ 50, BMIRefluxDeMeester No. of Mean %Relaxation RYGBP in pts with BMI >50. (kg/m2)SymptomScore Episodes LES of LES Results:Twentyseven pts (27/ 62=43.5%) were selected for Score Acid(mm hg) Lap Band (23F/4M;mean age 32.8, range:21-52 yrs;mean BMI Reflux 43.8, range 35-51);the other 35 pts (56.5%) underwent Gastric Pre- Bypass, 17/ 35 (48.6%) performed via laparoscopy (16F/ 1M; Operative55 2.2 35 116 23.7 212 mean age 34.2, range 19-50 yrs;mean BMI 44.6, range 39-50), Post- the remaining via laparotomy (11F/7M mean age 38.4, 20–56 Operative33 0.16 5.7 21 29.8 117 yrs;mean BMI 52.7, range 30-64) .No mortality was observed. p-Value0.002 0.003 0.14 0.05 0.45 0.03 One patient (5.9%) was converted to open tecnique for a pos- Conclusion:The results of this pilot study suggest that gastric terior wall leakage of gastroenteric anastomosis detected by bypass surgery for morbid obesity improves GERD both symp- methylene blue test. Concomitant cholecystectomy was per- tomatically and objectively.There appears to be no deterioration formed in 7 patients.Mean post operative hospital stay for open in esophageal motility in the short-term, and preoperative motil- and laparoscopic bypass was 8±5 and 5±3 days, respectively. ity disorders may be predictive of persistent postoperative Postoperative wound infection was observed in 10/18 (55.5%) GERD. patients undergoing RYGBP and in 1/17 (5.9%) patients operated by laparoscopy.Mean post-operative BMI at 6th month fol- 103.PROPHYLACTIC CHOLECYSTECTOMY WITH GAS- low up, already performed on 9 pts with RYGBP and on 6 pts TRIC BYP ASS OPERATION – INCIDENCE OF GALLBLAD- with LRYGBP, was 31.8±7.2 and 29.1±9.8 respectively. DER DISEASE. Conclusion:Differently from LASGB ®, training in open Daniel Igwe Jr.MD , Malgorzata .Stanczyk MD, Basil Felahy, MD RYGBP is required to safely approach the same operation by FRCS, Hoil Lee MD, E.James MD, Nicole Fobi MD, MAL Fobi, laparoscopic techniques.Selection of patients with BMI £ 50 is

408 Obesity Surgery,11, 2001 Crete Abstracts advisable in the beginning period of LRYGB. inserted through a small gastrotomy in the main stomach, its point brought out through the upper staple line close to the 105.LEAKAGE AFTER ROUX-EN-Y GASTRIC BYPASS. lesser curve.The gastrotomy is closed and the pouch is com- A.Westling MD , PhD, Sundbom MD & Gustavsson S Assoc pleted with a second application of the linear cutting stapler, Prof. University Hospital, Uppsala, Sweden from the bottom of the first one up to the angle of His.This row Background:Leakage is a feared complication to Roux-en-y might need oversewing for haemostatic reasons.The Roux-Y- Gastric bypass (RYGBP). Our report deals with leaks that have loop is then brought up behind the stomach and colon. The occurred during the recent 5-year period. CEEA is introduced through a jejunotomy, an end-to-end anas- Methods:A total of 285 patients underwent RYGBP during tomosis performed and its integrity checked.The jejunotomy is 1996-2000.In 94 patients (median BMI 38 kg/m 2) RYGBP was closed, and an enteroanastomis performed, according to patient a revisional procedure after previous failures with VBG and BMI between 80 and 225 cm below the pouch-jejunal anasto- banding procedures. 191 patients (BMI 44 kg/ m 2) had not mosis.All patients were started on oral intake day 1 postop.and undergone obesity surgery before. 44 procedures were done discharged at a daily intake of 2000 mls with prescriptions for laparoscopically and 30 with Hand-assisted laparoscopic tech- supplementary iron and vitamins incl.B12. They were followed- nique.In revisional procedures the gastro-jejunostomy was up in the outpatient department at 1, 3, 6 and 12 months, and either hand-sewn or constructed with linear stapler + manual thereafter annually. closure of defects.In the first 116 primary cases the anastomo- Results:Since October 1997 we have performed 181 such sis were made by linear stapler but in the most recent 75 anastomoses in consecutive patients with no leaks, no gastro- patients a circular stapling technique was used.We did not over- gastric fistulae and no mortality.100 were primary operations sew any staple lines, neither did we do any attempts to check and 81 revisional procedures following failed VBGs or for leaks intraoperatively. Postoperatively all patients were (adjustable) gastric banding. Mean operative time in primary supervised carefully at the surgical ward.Per oral contrast stud- operations was 91 minutes and operative blood loss was 121 ies were performed on wide indications but not routinely. mls, 350 in revisional.Postoperative hospital time was 4.6 (3-9) Results:We had a total of 5 patients with clinically significant days (median, range) with no difference between primary and leakage requiring emergency re-operation.Four leaks occurred revisional operations.BMI at operation, 1 and 3 years were for after revisional procedures (4 %) while only one leak (0,5 %) primary procedures 47.5, 29.5 and 28.7.For revisional proce- was observed after RYGBP performed as the first bariatric pro- dures corresponding values were 39.3, 30.8 and 32.1. There cedure.Relaparotomy was undertaken at postop day 1 (n=1), have been three symptomatic jejunal ulcers.Four patients had day 2 (n=3) and day 4 (n=1).One leak occurred after linear sta- clinically significant reflux preoperatively; it has resolved in all pling and at laparotomy we were able to identify the leaking spot four.No patient has developed reflux problems. T wo patients in that part of the anastomosis that had been hand-sewn.In the have had their pouch-jejunal anastomoses dilated, 8 and 12 remaining four patients we could not identify the exact location months postoperatively.One of these patients had a longstand- of the leak.In one case we suspected that the gastric stapling ing history of ulcer. Stricture formation recurred quickly after had failed because this patient developed a gastro-gastric fis- dilatation and she had her anastomosis refashioned without tula.No leakage has been observed after circular stapling tech- complications.No patient has needed hospitalisation for mal- niques.All patients were treated with large-bore drainage tubes nourishment. and antibiotics.The median (range) number of days with venti- Conclusion:A new technique for gastric bypass was intro- latory support, in ICU and in the surgical was 1 (0-5), 4 (2-9) duced.It gave short operating times and short hospital stay.The and 21 (19-36), respectively.No mortality. morbidity was low, with no leaks and no mortality .Three-year Conclusion:Leakage in the gastro-jejunostomy is a serious weight data show good results, on par with what is found in the complication after RYGBP requiring re-laparotomy , ICU treat- literature. ment and prolonged hospital stay and convalescence.Leakage occurs more frequently after RYGBP as a revisional procedure. 107.LAP AROSCOPIC GASTRIC BYPASS: RESULTS IN 76 PATIENTS. 106.A NEW TECHNIQUE FOR MAKING A FULLY STAPLED Hans Lö nroth, T orsten Olbers, Lars Lundell. Department of DIVIDED GASTRIC BYPASS: 1-3 YEAR RESULTS. Upper GI-Surgery, Sahlgrenska University Hospital, J.Hedenbro, S. F.Frederiksen, M. Flemming. Department of Gothenburg, Sweden. Surgery at Lund University hospital, Lund, Sweden Background:Gastric by-pass (GBP) is by many considered Background:Gastric bypass with Roux-en-Y reconstruction is as the “gold standard”in bariatric surgery.The technique com- the bariatric procedure of choice.The evidence support a small bines excellent weight reduction with few eating disturbances. pouch separated from the main stomach.The major hazard with This operation has since 1995 been carried out with laparo- this operation is the difficult upper anastomosis, where a leak scopic technique.Result from our initial series of 76 patients is jeopardises patient life. The terminal anastomosis is a logical hereby presented. choice, for ease of approach as well as because of gastric vas- Methods:During the period October 1995 to March 2000 76 cular anatomy.Another risk factor to consider is that of staple consecutive patients were operated on with a laparoscopic line dehiscence, jeopardising long-term weight development.It GBP.In the first 6 patients an anticolic omega-loop was con- thus seems desirable to have a full separation of the gastric structed, thereafter 25 patients were operated on with a retro- pouch.We have devised a way of making a fully stapled gastric colic, retrogastric Roux-en-Y construction.In the last 45 patients bypass with complete separation of the pouch.Operative data the Roux-limb has been placed anticolic and antigastric. and intermediate term (1-3 years) follow-up data are presented. Perioperative data were collected and the patients were fol- Method:The stomach is first partially transected perpendicu- lowed prospectively postoperatively with respect to weight lar to the lesser curvature 4.5-5 cm below the cardia with a lin- development, re-operations and eating disturbances. ear cutting stapler. The anvil of the CEEA 28 mm is then Results:Three patients were converted to open surgery

Obesity Surgery,11, 2001 409 Crete Abstracts because of a large steatotic left liver lobe. There were three hole in the left lower corner of the gastric pouch and pulled postoperative leakages; two at the gastroenteroanastomosi s down to be retrieved near the transverse suture line. and one at the enteroanastomosis.All of them were early iden- The patient is placed in the Trendelemburg position to retrieve tified and re-operated.Six patients had postoperative bleeding the Treitz ligament and measure a biliopancreatic limb of 40 to where two was re-operated though without finding of a definite 200 cm depending on the BMI.A side-to-side anastomosis is bleeding source. One patient succumbed after developing made by using a linear stapler and the enterostomy is closed dilatation of the remnant stomach with following peritonitis and manual or mechanically.The alimentary limb is passed to the multi organ failure.Three patients have been re-operated due to upper abdomen following a retrocolic, retrogastric way, using a ileus (10 days, 5 weeks and 5 years postoperatively).All of them Penrose drain as a traction device. were operated with the retrocolic Roux-en-Y construction.One The circular stapler is introduced directly through the access patient has been operated for a perforated ulcer. Six patients opened by a 18mm port into the blind end of the Roux limb to reported vomiting, most often due to overeating.Four patients create an end-to-side gastrojejunostomy, which is calibrated to reported dumping symptoms. The weight development corre- the internal diameter of the stapler (12 mm). sponds to a 70% reduction of excess body weight at 1-2 years postoperatively.This weight reduction has been rather consis- 110.BIG GUYS - LAP BANDING FOR SUPER OBESITY. tent in the follow-up period. George A Fielding. Wesley Hospital and Royal; Brisbane Conclusion:This series contains all the patients who were Hospital, Brisbane, Australia operated during the development of a totally new technique to This video outlines the pre-operative, peri-operative and post- perform GBP laparoscopically.You must bear this in mind when operative course of three super obese men weighing 335kg, you notice a somewhat high frequency of complications includ- 285 kg and 275 kg.It shows two of them discussing their feeling one death. Per today we consider laparoscopically per- ings prior to surgery and how they feel post-operatively. formed GBP to be a safe operation where the results concern- It also includes some operative footage of the third of these ing weight development and eating quality is comparable to super obese men. those seen after GBP done through a laparotomy. The purpose of the video is to highlight the great benefit that even the massively super obese can derive from morbid obesity VIDEOS: surgery.Laparoscopic placement of a BioEnterics Lapband in all three cases. 108.MICROPOUCH GASTRIC BYPASS. James A. Sapala, MD, Michael H. Wood, MD, Michael P . 111.LAP AROSCOPIC GASTRIC BYPASS WITH MANUAL Schuhknecht, DO, Thomas M. Flake, Jr., MD, M. Andrew ANASTOMOSIS. Sapala, MD. St. John Detroit Riverview Hospital, Detroit, MI, Antonio Cascardo, Silvio Albarrací n, Adrian Alvarez. IMETCO USA (Multidisciplinary Institute Specialized in the Treatment and the This video describes the major technical features of the Surgery of Obesity). Micropouch Gastric Bypass.These include mobilization of the After Higa K.publications, we have assisted to a very impor- gastric fundus, transection of the left phrenoesophageal liga- tant evolution of the Laparoscopic Gastric By-pass Surgery.Our ment and a single layer closure of the retro-colic Roux en-Y gas- technique is done through the following steps: Confection of trojejunostomy.It also illustrates the use of hemaseel fibrin glue Gastric micropouch of 20 cc, with 45 articulated cutting linear to “seal”the anastomosis. endosuture (Ethicon).Enteral section at 20 cm of angle of Treitz. The micropouch operation has been performed by our group Entero-enteroanastomosis with manual closing of enteral open- for seven years.In more than 1660 patients the micropouch has ing, of one to two meters depending on the obesity of the not required revision for pouch enlargement, marginal ulceration patient.The retrogastric, transmesocolonic handle is increased. or staple line dehiscence.Percent excess weight loss was 68.8 Manual Gastro-enteral Anastomosis in two planes, with gauged at one year and 76.6 at two years following operation. These stoma of 12 mm. Fixation with two sticks of anterior face of results equal or surpass those reported after other gastric stomach to peritoneum, repaired with titanium clips. bypass operations utilizing the 30cc pouch. The micropouch allows us to have a strict restrictive com- pound.The manual suture with narrow stoma, a good retaining 109.LAP AROSCOPIC GASTRIC BYPASS EXACTLY REPRO- with less possibility of stances, shorter surgical time, safe and DUCES THE OPEN TECHNIQUE. notoriously cheaper anastomosis. Díez del Val I, Martínez Blázquez C, Vitores López JM, Sierra The preparation for a gastrotomy seems to us extremely Esteban V, Valencia Cortejoso J, Sardó n Ramos JD. Hospital important in case of fistulae (for enteral feeding and disfunc- Txagorritxu, Vitoria-Gasteiz, Spain. tionalize) or in order to allow the future study of the residual Laparoscopic surgery has drastically improved the outcome stomach. of patients after gastric bypass:abdominal discomfort, respiratory and abdominal wall complications have almost disappeared 112.IMPLANTABLE STIMULATOR (IGS TM) FOR TREAT- and hospital stay has been shortened.After a 3-year experience MENT OF SEVERE OBESITY: INITIAL EXPERIENCE IN with Roux-en-Y isolated gastric bypass and more than 150 GREECE. patients operated on by this technique, we currently perform the J.Melissas, G. Schoretsanitis, J. Michalakis, H. Sanidas, G. laparoscopic procedure reproducing step by step the open Georgopoulou. Bariatric Unit, Dept.Surgical Oncology approach. University Hospital, Heraklion Crete Greece. First of all, a small isolated gastric pouch is constructed, Background:The implantable gastric stimulator, is a recent starting at the lesser curvature 5 cm distal to the gastroe- investigational method for treatment of clinically severe obesity. sophageal union to reach the angle of His.T o avoid esophageal This study describes the initial experience from the first implan- injury, the anvil is introduced transabdominally through a small tations, in Greece.

410 Obesity Surgery,11, 2001 Crete Abstracts

Methods:5 morbidly obese female patients underwent sels and the use of the harmonic scalpel enable the redundant implantation of gastric stimulator. Mean age was 28.6 years fundus and gastric body to be safely removed.The sleeve gas- mean weight was 121 kg and mean BMI 42.9.The implantation trectomy leaves a narrow gastric tube between the gastro- was performed under G.A.The lead was implanted laparoscop- oesophageal junction and the antrum ically using 4 ports in a high position of the lesser curve. Content:This video demonstrates the technique of laparo- Simultaneous gastroscopy was performed to exclude lead pen- scopic sleeve gastrectomy. The patient preparation and port etration into the gastric mucosa.We used two grasping instru- positions are shown.The greater curve and fundus of the stom- ments to hold the stomach.The lead was fixed to the anterior ach are mobilised using the harmonic scalpel, within the gastro- stomach wall by 2-0 silk stitch. The electric pulse generator epiploic arcade, with division of the short gastric vessels.The implanted simultaneously in the subcutaneous tissue of the lesser sac is freed of adhesions and the gastric tube fashioned abdominal wall anteriously to the left rectus sleeth and secured over a 32Ch bougie, using an angled EndoGIA (USSC) stapler. in place with the application of a single silk No 0 stich. The staple line is oversewn with a continuous suture and the Results:Mean implantation time was 50 min.Simultaneously excised gastric body removed within a tissue retrieval sac. gastroscopy revealed penetration of the lead into the stomach in one patient.The lead was then replaced without further conse- 115.TECHNICAL STRATEGY OF HALS-GASTRIC BYPASS quences.No serious complications intra or postoperatively were FOR THE SUPER/SUPER OBESE PATIENT. seen.All patients recovered well and left the Hospital the first Isao Kawamura MD 1, Kazuma Yamazaki MD 1, Masaaki Kodama postoperative day. MD1, Okamichi Morikawa MD 1, Yukimasa Miyazawa MD 2, Conclusions :From the technical point of view, implantation of Takenori Ochiai MD 2. JA Marronnier Medical the gastric stimulator (IGSTM ) is a simple technique.Providing Center,Shimotsuga General Hospital 1 Department of Surgery , that this new method will prove its efficacy in reducing body Chiba University School of Medicine 2 weight, it will be a very good tool for management of clinically Because of insufficient clinical-results of vertical banded gas- severe obesity. troplasty or K-gastroplasty for the patient of super/super obesity, we have been performing HALS (hand assisted laparoscopic 113.THE USE OF A NITINOL U-CLIP (COALESCENT surgery) roux-en Y gastric bypass for them.Although we have SURGICAL INC) FOR ADVANCED LAPAROSCOPIC had excellent effect of body weight reduction of them after the PROCEDURES INCLUDING GASTRIC BYPASS. operation, occasionally we have had to encounter the difficulties Marina S.Kurian, MD, Valavanur Subramanian, MD, Mitchell S. during and immediately after the operation.The most hazardous Roslin, MD. Department of Surgery , Lenox Hill Hospital, New complication of the operation is the occurrence of the leakage York, NY, USA of anastomosis between small gastric-pouch and roux-en Y Nitinol, which is a combination of nickel and titanium, has limb. several unique properties. These include favorable handling In order to prevent the insufficient anastomosis of them and characteristics and the ability to return to it’ s prefabricated to extend this operation in general, we have contrived to set-up shape.These properties have been utilized for medical applica- the Anvil of 21mm CEAA (circular stapler) in the small gastric tions in the central nervous system and coronary stents.A niti- pouch,that must be one of the key to overcome it.We routinely nol clip (U -CLIP, Coalescent Surgical Inc) has been recently insert it with special guide-tube orally with the contrivance to introduced for minimally invasive cardiac surgery.The clip has accomplish the anastomosis. the appearance of a more rigid suture with memory and is We have performed this operation for three super/ super placed with standard instrumentation.After placement, the clip obese patients,which had different post operative course with is deployed with a simple squeeze of the needle holder, thus these contrivances. eliminating knot tying. Clips with larger circumference (.080- .120in) have been developed for gastrointestinal attachments. 116.GASTROENTERIC BY-PASS: MODIFICATION OF THE The advantage of the nitinol clip is that it offers the flexibility of TECHNIQUE. suture, combined with easy handling and rapid deployment with Antonio Cascardo, Silvio Albarrací n, Adrian Alvarez. IMETCO no additional instrumentation.Tissue incorporation is similar to (Multidisciplinary Institute Specialized in the Treatment and the staples since the exterior surface, titanium oxide, is the same. Surgery of Obesity). In the video, we will show a novel technique for suturing with Since 1967, when Mason and Ito described the gastroenteric application for purely laparoscopically hand-sewn or combina- By-pass as a bariatric technique, it has gone through many tion stapled/ sutured anastomoses with the U-Clip for gastric modifications until it became the “ The Standard Gold” of the bypass.Additionally , video showing the clinical use of the clip in surgeries and the favorite for the experienced surgeons. vascular attachments will be shown. Potential applications for Fobi in 1991 and then Capella add variants so as to decrease laparoscopic surgery will be discussed. the reservoir of the stomach, to regulate the stoma of exit and the worry for the study of the residual stomach, adding a ruled 114.LAP AROSCOPIC LONG VERTICAL GASTRIC STA- gastrotomy. PLING ±SLEEVE GASTRECTOMY FOR THE TREATMENT In 1994 Wittgrov and Clarke published 5 cases of By-pass OF MORBID OBESITY. through laparoscopic way, complex technique with a hard curve Michael J McMahon, Simon PL Dexter, George Delibaltadakis. of learning.The illnesses of the residual stomach described in Leeds Institute for Minimally Invasive Therapy , The General the literature are severe: peptic ulcers and gastric cancer, Infirmary, Leeds, UK among others.There are publications of techniques with ecog- Background:Long vertical gastric stapling (the Magenstrasse raphyc guides to make percutaneous gastrotomies for the study and Mill operation) has been the standard gastric restrictive pro- of residual stomach post by-pass. cedure used for morbid obesity in our institution over the last 10 The Laparoscopic technique as well as the Laparostomic one years.At laparoscopic surgery access to the short gastric ves- of IMETCO, makes a gastric micropouch of 20 cc with articu-

Obesity Surgery,11, 2001 411 Crete Abstracts lated 45 endocutter, or 75 TLC (Ethicor); manual gastroen- patients above 50 being submitted to RYGB or BPD rather than teroaostomosis leaving an exit stoma of 1,2 cm.measured and LAGB or VBG. Adjustable gastric banding gave the lowest gauged.Entero-entero anastomosis from one to two meters of weight loss rate of all procedures and was associated with a the angle of Treitz, according to the obesity and the alimentary similar complications rate as compared to other procedures. habits of the patient. VBG, RYGB, BPD&DS gave good weight control with a low We conclude every operation fixing the anterior face of the complications rate except for the incisional hernia rate that was residual stomach with two sticks to the peritoneum repaired with common after open procedures. titanium clips.This way, we leave a future percutaneous gastrotomy of an easy completion in an XR room. 118.COMBINED SURGERY FOR MORBIDLY OBESE WITH If necessary, in the immediate post-operation for decompres- REFLUX ESOPHAGITIS. sion, if there is an acute gastric dilatation, or so as to disfuc- Alaa Abbass S. Moustafa, Essam Abd el Gelil. Ain Shams tionalize Gastroenteral anastomosis and to feed in an enteral University and Ahmed Maher Teaching Hospital, Cairo, Egypt. way in case of fistula. Background:Sliding hiatus hernia and reflux oesophagitis are In the distant post operation, if necessary, it can be done for common among the morbidly obese.There is a risk of increas- the excluded gastroenteral tractus study.This way, the inconve- ing the peptic oesophagitis after gastric restrictive surgery. T o nience of systematic gastrotomy is avoided, which is unneces- avoid denying indicated patients or facing the problem of dis- sary in the majority of the patients, and the use of more complex ease exacerbation after surgery, we investigated the combined techniques to obtain it is also avoided. surgery of antireflux and gastric restriction for morbidly obese patients with reflux oesphagitis. 117.A COMPARATIVE STUDY BETWEEN FOUR BARIATRIC Methods:30 patients( 22 females, 8 males) were treated sur- PROCEDURES: IS THERE AN IDEAL PROCEDURE YET? gically for morbid obesity and reflux oesophagitis between 1998 Khaled Gawdat, MD. Ain-Shams School of Medicine, Cairo, and 2000.T oupet partial fundoplication combined with vertical Egypt. banded gastroplasty V .B.G.was performed . Median age of Background:Many surgical options are currently available for patients was 34 ( range 20-51), and preoperative median B.M.I. treating morbid obesity.We present the results of a comparative was 49 ( range 40-55 ). All operations were done by open study between four different bariatric procedures with < 55 surgery. months of follow up. Results:Operative time was 55-130 ( median 70 min). No Methods:340 morbidly obese patients where operated upon remarkable intraoperative or postoperative complications were by a single surgeon with a follow up period of £ 55 months.The encountered.During follow-up satisfactory control of reflux mean age was 33.9 years and 78.1% of our patients were oesophagitis was achieved .At one year mean weight loss was females.The mean weight was 147.4 kg with a mean BMI of 45 Kgm and mean excess weight loss was 60%.Median hospi- 55.3kg/m2 and the mean EBW was 88.7 kg.For every patient, tal stay was 4 days. one of four procedures was chosen, either a vertical banded Conclusion:Combined surgery is a good option for the mor- gastroplasty (VBG) (N: 225), or Laparoscopic adjustable gastric bidly obese with reflux oesophagitis.It is better than facing the banding (LAGB) (N: 40), or Roux-en-Y gastric bypass (RYGB) problem postoperatively to plan its management preoperatively. (N: 56) or a bilio-pancreatic diversion with duodenal switch (BPD&DS) (N: 19).Procedure choice was based on preopera- 119.ELECTROGASTROGRA PHY IN MORBIDL Y OBESE tive age, weight, eating habits, bowel habits and economical PATIENTS. status.Outcome of the 4 procedures was compared in terms of Francois van Dielen*, Freek Daams**, Bas de Cock*, Robert- complications, weight loss, co-morbidity improvement and life Jan Brummer**, Jan Willem Greve*. Dept.of General Surgery* style. and Gastroenterology**, University Hospital Maastricht, The Results:At 24 months postoperatively LAGB patients lost Netherlands. 31% of excess weight (%EWL), VBG patients lost 69% EWL, Background:Electrogastrography (EGG) is a new technique RYGB patients lost 72%EWL and BPD&DS patients lost to study gastric myoelectrical activity (gma). The aim of this 78%EWL.Failure to reach 40% EWL occurred to 42.5% of the study was to compare gma in lean and morbidly obese subjects LAGB patients and to 16.6% of the VBG patients and to 1.7% of (MO) and to investigate the effect of LapBand on gma in MO. the RYGB patients and 0% of the BPD&DS patients.LAGB Methods:To determine gma, EGG was performed in 12 MO patients had a 12.5% complications rate (2 band erosions, 2 (age:42.9 ±13.0;BMI: 48.5 ±5.7) preoperatively (preop) and port dislocations, 1 port infection) with a 10% re-operation rate, 12 lean (age:27.8 ±12.2 years;BMI: 21.8 ±1.4).Next to this, VBG patients had an 8.9% complications rate (12 incisional her- EGG was performed in these 12 MO 3 months postoperatively nias, 3 pouch obstruction, 1 mesh migration, 1 gastritis) with a (postop).Six electrodes were placed on the abrased skin. A 5.6% re-operation rate.RYGB patients had a 10.7 % complica- fasting state recording of 30 min.was followed by a standard tions rate (4 incisional hernias, 1 anemia, 1 intestinal obstruc- testmeal and a postprandial recording period of 30 min.The fol- tion) with a 7.6% re-operation rate. BPD&DS patients had lowing EGG-parameters were determined in both fasting (f) and 10.5% complications (2 incisional hernias) with no re-opera- postprandial (pp) state:dominant frequency (DFf/pp), dominant tions.Solid food intolerance occurred in 30% of the LAGB power (DPf/ pp), dominant power instabili ty coefficie nt patients and in 17.7% of the VBG patients and in 5.7% of the (ICf/pp=SD of DP/ mean DP) and power ratio (PR=mean RYGB patients, while none of the BPD&DS patients had food DPpp/mean DPf). intolerance. Results:ICpp significantly (p<0.05) decreased in MO com- Conclusion:There is no single procedure that works for all pared to lean (MO:ICpp=0.24 ±0.07;lean: ICpp=0.29 ±0.06). patients but there is an ideal bariatric procedure for every DFpp significantly (p<0.05) increased in lean (DFf=2.86 ±0.16, patient.The choice of procedure should be individualized per DFpp=3.03 ± 0.15) and MO (DFf=2.94 ± 0.17, DFpp=3.0 ± patient with super-obese patients, sweet eaters and female 0.17).PR did not differ between MO and lean.After operation

412 Obesity Surgery,11, 2001 Crete Abstracts

BMI decreased from 48.5 ±5.7 to 43.6 ±5.6 (p<0.01).DFpp sig- (mean follow-up 43 months) after a Lap-Band procedure. nificantly (p<0.05) increased from 2.99 ±0.17 preop to 3.11 ± Erosion cases were studied retrospectively. 0.25 postop.Furthermore, a significant decrease of DPpp was Results:Five patients (1.5%) developed erosions.Each time, found (preop:DPpp= 3242 ±1736;postop: DPpp= 2038 ±877; laparoscopic removal of the Lap-Band was carried out shortly p<0.05).However, no significant difference was found for PR, after the diagnosis.No postoperative complication occured.The DFf, DPf, ICf and ICpp in MO preop and postop. first four patients have received a new Lap-Band four to five Conclusion:This study showed differences in gastric myo- months after removal. For the first patient conversion from electrical activity between morbidly obese patients and lean.The laparoscopy to laparotomy was required, and for the other three ICpp in morbid obese subjects was significantly lower compared patients the procedure was carried out laparoscopically.Again, to lean.Moreover, after LapBand DPpp decreased significantly. no complications occured and the four patients are doing well These findings might suggest lower contractile stomach activity 17, 12, 11 and 9 months after the rebanding procedure respec- in MO after a meal compared to lean, which even more tively.Gastroscopy revealed re-erosion in none of the cases. decreases after LapBand operation. Conclusion:Lap-Band erosion is a bothersome late complication after laparoscopic adjustable gastric banding procedures 120.IS THE LAP AROSCOPIC REBANDING FOR POUCH and requires band removal.This can be done laparoscopically COMPLICATIONS AFTER LAP AROSCOPIC GASTRIC in a safe way.There is usually a request for another bariatric BANDING THE RIGHT CHOICE? procedure and rebanding is a feasible and safe option.In order M. Weber1;M.K.Müller 1; F. Horber2, L. Krähenbü hl 1, R. S. to determine the value of this treatment, a prospective study is Hauser3. 1UniversityHospital Zürich; Clinic for Visceral Surgery, being conducted which involves following 10 to 20 rebanded Zürich, Switzerland, 2Klinik Hirslanden, Zü rich, Switzerland, erosion patients for three years with routine endoscopy at one, 3Consultant for Nutrition, Zürich, Switzerland two and three years after rebanding.The aim is to gain answers Background:Thousands of gastric bandings have been per- to questions as to 1.the effect on patients’weight, 2.whether formed during the last years in Europe. There are increasing erosions will redevelop and 3. whether other problems will data that in the long-term follow-up an incidence of pouch com- occur. plications of more than 15% must be expected.These complications can be treated by debanding, rebanding or other 122.LAP AROSCOPIC ADJUSTABLE GASTRIC BANDING: bariatric procedures.The aim of this analysis was to evaluate PERSONAL EXPERIENCE. the efficiency of rebanding after primary failure of the gastric Marcello Lucchese, MD, Andrea Valeri, MD, Giovanni Cantelli, banding. MD, Ingrid Paulin, MD , Saverio Reddavide, MD, Domenico Methods:Between 1997 and 2000 the data of 26 cases with Borrelli, MD. Dept.of Gen. and V asc.Surgery , Policlinico di a laparoscopic rebanding have been assessed prospectively. Careggi, Florence, Italy Results:Patients with a pouch complications had either an Background:Laparoscopic adjustable silicone gastric band- insufficient weight-loss or the obstruction lead to vomitus and ing (LAP-BAND ®) may perhaps provide the best results with food intolerance.After an interval of 605 days (range 69-1400) minor risks for weight loss, especiall y if performed by patients were operated again. Then, a new band had to be laparoscopy.The aim of this study is evaluate short and long- implanted or the preexisting band was repositioned and refixed term complicat ions observed in pts. operated on by again.Only in one case we had to convert to open surgery laparoscopy. because of a bleeding (conversion rate:3.5%). The mean hos- Methods:302 patients, aged 16-62 years, with a mean BMI of pital stay was 4.4 days (2-11). The mean Body-Mass-Index 48.5 kg/m2 (36.5-70.8) were operated on since 1992 in our insti- (BMI) before primary banding was 45,9 kg/m 2, the fat mass was tution, 117 of which by laparotomic approach (including 72 pts. 63.3 kg. The mean BMI before rebanding was 38 kg/ m 2, the by original Kuzmak’ s banding) and 185 by laparoscopy .In 6 mean fat mass was 44.15 kg.After rebanding with a follow up of (3.7%) of these last cases we had to convert to laparotomy.In 8 592 days (35-1386) we found a mean BMI of 38,8 kg/m 2, and a pts.we associated colecistectomy and in 2 pts.hiatoplasty . mean fat mass of 47.4 kg. Results:Regarding our 185 laparoscopic operations, periop- Conclusions :The laparoscopic gastric rebanding can be per- erative complications were stomach wall perforation recogna- formed safely in so called pouch complications after laparo- tized and sutured intraoperatively in 2 pts.(1.2%), p.o. pneu- scopic gastric banding.However, in our series the laparoscopic mothorax in 2 pts.(1.2%) and pulmonary embolism responding rebanding did not result in a further weight loss.Therefore, the to medical therapy in one patient (0.6%). The most common indication for rebanding in case of pouch complications has to complication in the laparoscopic series was irreversible pouch be questioned, since the underlying cause (e.g.eating disorder) dilatation which occurred in 7 cases (3.1%) always requiring might still be present.We recommend to consider other surgical reoperation.It consisted in band removal due to pt’s choice by procedure, such as laparoscopic gastric bypass. laparoscopy in 3 cases, laparoscopic band repositioning in 1 case and band removal associated to DBP with stomach 121.LAP-BAND EROSION: INCIDENCE AND A WAY OF preservation in 3 pts.Moreover one patient wanted to remove TREATMENT. the band by laparoscopy for weight loss absence and another Erik Niville. Ziekenhuis Oost Limburg Genk, Belgium one required band removal with classical DBP for weight regain. Background:Laparascopic adjustable gastric banding is an In one patient (0.6%) we observed band migration (erosion) at effective and safe surgical treatment for morbid obesity. four months from operation presenting a port site sepsis and Migration of the band through the stomach wall is a well-known required band removal.In 6 pts.(3.7%) we observed the con- late complication that requires band removal. After band necting tube rupture which required a laparoscopy.This obvi- removal, there is usually a request for a second bariatric proce- ously advised us to change the port site in the last cases.In dure. other 5 cases we noted a port leakage and we changed it. Methods:333 patients were followed for at least two years Conclusions :LASGB seems to be a safe procedure in the

Obesity Surgery,11, 2001 413 Crete Abstracts treatment of severe obesity with a low rate of complications but Self-esteem 4.40 (3.33-5.47) 5.95 (5.10-6.81) 0.019* it requires a very strict patient follow up and a good patient Sexual life 2.70 (2.15-3.25) 2.71 (2.15-3.27) 0.872 selection by a multidisciplinary team. Activities of daily living 1.75 (0.93-2.57) 4.33 (3.61-5.06) <0.001* 123.ADJUSTABLE SILICONE GASTRIC BANDING FOR Comfort with REVISION OF FAILED GASTRIC BARIATRIC food 6.55 (5.99-7.11) 6.38 (5.8-6.97) 0.716 PROCEDURES. Total score 27.6 (22.04-33.16)39.86 (36.57-43.15)<0.001 Sholmo Kyzer, Aznat Raziel, Ofer Landau, Alexander Matz, Ilan Conclusions :LGB results in significant EBW loss and Charuzi. Department of Surgery “B”, E.Wolfson Medical Center, improves quality of life in the medium term. Holon, Israel Background:Revision of gastric bariatric operations is some- 125.INTRAGASTRIC BALLOON TECHNIQUE FOR THE times technically difficult and may fail to achieve prolonged TREATMENT OF SEVERE OBESITY: SHORT-TERM AND weight reduction. The use of the adjustable silicone gastric MID-TERM FOLLOW-UP OF THE FIRST 52 P ATIENTS IN banding (ASGB) offers a new approach for these revisions. ARGENTINA. Methods:ASGB was performed as a revisional procedure on Cormillot Alberto, LaRegina Rosana, Pozzoni Carlos, Diz 37 patients whose initial bariatric procedures were as follows: Alejandro, Argonz Julio, Fuchs Analia. Clínica de Nutrició n y silastic ring vertical gastroplasty (21), gastric bypass (12), hori- Salud, Buenos Aires, Argentina zontal gastroplasty (3) and vertical banded gastroplasty (1). Background:Severe obesity is a chronic desease that is very Results:The length of the procedure varied from 55 to 145 difficult to treat. Surgery to promote weight loss by restricting minutes (mean 83 minutes). Intraoperati ve complicati ons food intake is an option for patients with BMI>35 or important included two fundic tears which were sutured without any post- co-morbidities.Among the different bariatric interventions, operative sequelae.Five patients needed reoperation during the Intragastric Balloon Treatment is a minimally invasive alternative that do not requires profound anesthesia nor long inactivity.The first postoperative year due to gastric volvulus (1), tubing tear placement, the volume injection and the removal of the IB are (1) and development of postoperative ventral hernia (3).BMI fell performed endoscopically.The action of the IB is to partially fill from 44.8 ± 8.07 to 33.4 ± 6.9 Kg/ m 2 for patients reoperated the stomach, therefore inducing satiety. with BMI higher than 35 Kg/m 2 and from 29.2 ±3.32 to 25.4 ± Methods:From Oct. 2000 to March 2001, the first 52 2.8 Kg/m2 for patients operated with BMI lower than 35 Kg/m 2. Intragastric Balloons (IB) were placed in Argentina. Obese Conclusions :ASGB can be performed for revisions with an patients (29 women(w) and 23 men (m)) were mostly recruited acceptable complication rate and postoperative weight reduc- from the Cormillot Network for the Treatment of Obesity, accord- tion. ing to indicatio ns and restricti ons given by Bioenteri cs Corporation, after thorough clinical, biochemical and psychiatric 124.QUALITY OF LIFE FOLLOWING LAPAROSCOPIC GAS- evaluation.All patients had failed repeated weight loss pro- TRIC BANDING FOR OBESITY. grams and had a medical condition that would benefit from Reyad Al-Ghnaniem*, Andrew Dettrick§ , George Fielding§ , weight loss.They had been well-informed on the procedure and Ameet G Patel*. *King’s College Hospital, London, UK. §Wesley a consent form was signed. Expectations and follow-up plan Medical Centre, Brisbane, Australia (diet, physical activity and contacts) were discussed in advance. Background:To assess the impact of laparoscopic gastric Procedure characteristics:Device placed by direct endoscopic banding (LGB) on the quality of life of obese patients. visualization.The ballon is filled with variable volumes of saline Methods:A validated questionnaire (IWQOL) was sent to 37 and Methylen Blue to detect any leakage, in order to individual- patients who underwent LGB and 21 consecutive obese ize patient treatment(450 to 600 cc).It has a self-sealing valve patients who were accepted for LGB (controls).The question- and a radiopaque valve cap. naire was composed of 8 parts (74 items) and covered health, Results: Intervention time was 8 to 20 min.under mild seda- social/interpersonal, work, mobility , self-esteem, sexual life, tion.with Medazolan.Preoperative BMI were 35 to 53 for w and activities of daily living and comfort with food.The patients’body 38 to 67 for m. Gastroscopic findings were 4 gastritis gradeI mass index (BMI) was recorded before surgery in the LGB (2diagnosed asHelycho bacter Pylory later) and 1polip group and at the time of the study in both groups. (benign).Patients were able to walk to the recovery room and Result:Twenty-one (57%) LGB patients and 21 controls had a mean hospital stay of 2 ±1days.Immediate complications (100%) responded to the questionnaire.The patients’character- were vomits (80%), nausea (90%in w and 20%in m) epigastric istics were similar in both groups. The mean BMI of the LGB pain (55%), heartburn(40%), meteorism (15%).Five patients patients before surgery and for controls at the time of the study decided to remove the IB According to the date of implant, was 45.1 (40.5-49.8, 95% CI) and 42.6 (38.8-46.4, 95% CI), mean BMI change for w and m was -6 and - 4 in 6 months, -3.3 respectively (P= 0.473). The mean time since LGB was 21.3 and -3.2 in 4 months and -3 and -2.4 in 2 months.At the last months (19.1-23.6, 95% CI).During the follow up period there visit,patients were asymptomatic and continued losing weight. was a reduction in excess body weight (EBW) of 40.8% (31.5- About 40% complied with post surgical contacts. 50.2, 95% CI).The differences in quality of life scores are sum- Conclusions :Although patient expectations had been widely marised in the following table. discussed before balloon placement, they exceeded the weight LGB Controls loss actually achieved.More emphasis is to be placed on com- Parameter mean (95% CI)mean (95% CI) P pliance with follow up visits and support groups. Preliminary Health 3.7 (23.-51) 6.76 (5.86-7.66) 0.001* results have been satisfactory, thus encouraging to continue Social and inter- with IB placements.Second time placement of the balloon is a personal 2.65 (1.56-3.74) 4.9 (3.64-6.17) 0.007* further possibility for these patients. Work 2.45 (2.09-2.81) 2.71 (1.99-3.44) 0.580 Mobility 3.30 (1.77-4.83) 6.10 (5.02-7.17) 0.004* 126.BIOENTERICS INTRAGASTRIC BALLOON (BIB™) :

414 Obesity Surgery,11, 2001 Crete Abstracts

RETROSPECTIVE ANALYSIS. treatment of obese patients.With the first balloon-types a lot of D.Raemdonck*, P .Belva*, P .Rotsaert*, J.C. Lefebvre*, M. complications were mentioned with negative publicity. Newer Takkiedine*, P.Vaneukem*, A.Bailly **. Department of Digestive balloons were developped: round shaped, smooth surface, Surgery*, Department of Clinical Nutrition **, CHU Charleroi, radio-opaque, 6 month life, saline-filled. Charleroi, Belgium Methods:In 84 obese patients (61 females, 23 men), mean Background :Among the different available therapeutic tools age 37,6 years (14-58 y) with a mean BMI of 38 (25-71) an intra- to reduce obesity, Intragastric Balloons have been used over the gastric balloon was placed endoscopically in the stomach last two decades as a temporary device with various outcomes. together with a diet regimen. To test the efficacy of Bioenterics Intragastric Balloon (BIB™) in Results:In 76 patients 1 balloon was placed, in 5 patients 2 obese patients at short, medium and long term. balloons and in 3 patients even three balloons.In 8 patients the Methods:Between November 1997 and September 2000, 63 balloon had to be removed earlier because of intolerance.Four BIB™were endoscopically placed in 55 female and 8 male patients had a severe complication:one deshydratation, 2 angu- obese patients.The mean age was 34 (range 17-55).At admis- lar ulcers, one obstruction.In 45 patients the balloon was sion the mean weight was 111.2 kg (range 64-224 kg), the removed endoscopically, in 9 patients there was a spontaneous mean BMI was 40.4 (range 30-80) and the mean excess weight evacuation, in 9 patients the balloon is still present and 21 (EW) was 49.6 kg (range 12-108 kg).All patients were evalu- patients are lost to follow-up.After 6 months there was a mean ated preoperatively by a multidisciplinary team composed of a reduce of the excessive weight of 45%, after 9 months even dietetician, an endocrinologist, a bariatric surgeon and a psy- 56%.The mean BMI deminished from 38 tot 32.7.There was a chiatrist.BIB™ insertion was proposed to patients with BMI mean weight loss of 15 kg after 6 months, 20 kg after 9 months. between 30 and 40 because they did not match the inclusion Conclusions :Intragastric balloons can induce an effective criteria for a restrictive bariatric surgical procedure, to patients weight loss in a highly motivated subpopulation of obese with a BMI between 40 and 50 who choosed personally the patients.It gives the opportunity to learn an effective diet regi- intragastric balloon and to patients with a BMI over 50 in order men.The reduced maintenance is however difficult. It can be to loose weight before getting a more definitive bariatric surgical used in extreme obese patients before surgery. procedure.Comorbidity factors included 9 hypertension, 3 diabetes mellitus, 2 ischaemic cardiomyopathy, 2 hypercholestero- 128.THE NEW INTRAGASTRIC BALLOON (BIB): A FRENCH laemia and 1 severe lumbar arthropathy.Upper GI endoscopy EXPERIENCE OF 23 CASES, WITH ADJUNCTION OF A was achieved in each case under general anaesthesia and the HIGH-PROTEIN DIET. balloon was filled with 500 to 800 ml of saline after insertion. Jerome Dargent, MD, Laurence Poulain, Dietitian. Polyclinique Patients were discharged from the hospital 3 days post-op and de Rillieux. 941, Rue Capitaine Julien. France were reviewed clinically at different time intervals thereafter.A Background:The intragastric balloon (BIB) is now widely retrospective analysis of their outcome has been undergone. used in Europe, either in morbid or in severe obese.The preop- Results:26 patients were reviewed after 1 month;their mean erative use in morbid obese has not been an option in our expe- excess weight loss (MEWL) was 12.1% (range– 3-25%). 41 rience;we use to propose the BIB to patients with a BMI above patients were reviewed after 2 to 3 months;their MEWL was 30 and not eligible for bariatric surgery, and look for improve- 19.5% (range–6-41.5%). 34 patients were reviewed after 4 to 6 ment of short-term results. months;their MEWL was 28.5% (range–6-62.7%). 26 patients Methods:From April 2000 to January 2001, a new were reviewed later than 9 months after the BIB™ insertion; Bioenterics balloon was implanted in 23 female patients in our their MEWL was 22.5% (range–11.6-60.6%). We observed one institution.Mean age was 41 (32-57).Mean weight was 83 kg alimentary intolerance to the BIB™which required its removal 1 (73-95), mean excess body-weight was 30 kg (20-38), and month after insertion. No major complication such as gastric mean BMI 31,4 (30-38).All patients had a general anesthaesia. erosion, upper GI haemorrhage or bowel obstruction appeared. Patients were seen monthly post implant. When possible, a 23 balloons ruptured among which 14 passed in the stool on high-protein content diet was initiated from week 3 and main- average at 9 months post-op (range 4-16 months), 2 were vom- tained until week 12 after implant. ited at 6 and 7 months post-op and 7 were removed endoscop- Results:Mean weight-loss results after 6 months has been ically on average at 10 months post-op (range 6-14 months).7 15 kg (5-27), and excess weight-loss 15% (10-66).T wo patients balloons were deliberately removed after a significant weight did not tolerate the advised 500 cc inflation of the new BIB and loss on average at 10 months post-op (range 7-15 months). had it removed.This led us to inflate 450 cc to patients with BMI Conclusion:Despite a relatively poor follow-up rate, BIB™ under 35.The protein diet made it possible to increase weight- remains a safe procedure offering a moderate weight loss at loss of an average 3 kg, but only 30% of the patients could con- short and medium term to individuals lacking inclusion criteria tinue it from week 6 to week 12. for a more definitive bariatric surgical procedure.A good indica- Conclusion:We believe that intragastric balloon is an inter- tion could be high-risk and superobese patients. esting first-step procedure in treating severe or morbid obese.A strict diet follow-up is utterly requested;a high protein content 127.ARE INTRAGASTRIC BALLOONS USEFUL IN THE diet is likely to enhance short-term weight-loss. MANAGEMENT OF OBESITY? A.E.E.Elewaut. Department of Gastroenterology AZ 129.TREA TMENT OF MORBID OBESITY WITH INTRAGAS- Groeninge, campus OLV, Kortrijk, Belgium TIC BALLOON (BIB TM) IN ASSOCIATION WITH DIET. Background:Obesity can be treated with dietary manage- Santo Bressani Doldi, G.Micheletto, M.Perrini, M.C. Librenti*, ment, behavioral modification, medical therapy, jaw- wiring and/ S. Rella*. Cattedra di Chirurgia Generale dell’ Università degli or surgery .Dietary management and behavioral modification Studi di Milano-Istituto Clinico Sant’Ambrogio (Direttore:Prof. are safe but in many patients unsuccessful.Intragastric balloons S.B.Doldi); Centro per la Farcomacoterapia delle Malattie are since 1979 used as help for the non-surgical aproach of the Nutrizionali e Metaboliche “E.Genovese e R.Klinger” (Direttore

Obesity Surgery,11, 2001 415 Crete Abstracts

Scientifico: Prof.S.B.Doldi) *Unità di Malattie Metaboliche - selected cases and into multidisciplinary approach. Istituto Clinico San Siro, Milano, Italy 130.PRELIMINARY REPORT ON SURGICAL INTERVEN- Background: In our Centre of bariatric surgery since march TION ON PATIENTS WITH BMI>32 BUT<40 WITHOUT LIFE 1998 we have used the intragastric balloon (BioEnterics THREATENING COMORBIDITIES. Intragastric Balloon BIB ®) associated with restricted diet for the MAL Fobi, MD F .A.C.S. Center For Surgical Treatment Of treatment of obesity and morbid obesity.Here we refer the most Obesity, Tri-City Regional Medical Center, Hawaiian Gardens, significant results of our experience. USA Methods:Since march 1998 we placed 240 BIB in 217 obese Background:Surgical intervention is currently indicated for and morbidly obese patients : 59 were male and 158 female. patients with BMI>40 or >35 with life threatening comorbidities. Mean age:42.2 years (19-70);mean weight:kg 117.4 (67-229); Patients with BMI of 35-40 without these comorbidities do not mean BMI:41 (29-81).22 patients (13 female and 9 male) had only have the increase propensity to develop them but suffer a second BIB and one patient underwent a third balloon.All the from the same psycho-socioeconomic consequences as those patients were submitted to blood and instrumental screening. with BMI>40.These patients do not respond any better to non- After 24 hours of liquid diet the patients were subjected to endo- surgical treatment of their obesity.The question has been raised scopic placement of BIB in general anesthesia with orotracheal often why not offer them surgical intervention. A study was intubation.In 147 patients the BIB was removed after 4 months; undertaken to find out. a new pattern of balloon, introduced in march 2000, allowed to Method:A study was carried out to determine the outcome of maintain the BIB for 6 months in 93 patients.The mean balloon surgery on patients with BMI>32 but<40 without life threatening filling was 531 ml (350-700) of saline with 10 ml of methylene- comorbidities but with either psychological, economic or social blue.The patients were given a balanced diet of 1000 Cal per impairments affecting their quality of life. The approval of our day, with the temporary addition of omeprazole, vitamins and Hospital Internal Review Board was obtained and fifty patients oligominerals.Follow-up involved a monthly check-up with were entered into this study.In addition to the routine evaluation repeat routine blood tests and weight controls. If symptoms for surgical intervention these patients were required to have the such as nausea or vomiting are reported or there is weight gain, approval of their primary care physician, be seen pre-opera- the patient is subjected to an abdominal ultrasound or X-ray . tively by a psychiatrist and have a member of the family or a Removal of the balloon was performed under general anesthe- very close friend present at the time of the discussion of the sia with intubation.T o value the efficacy of BIB + diet treatment operation risk and follow up requirements.They committed to at vs.diet alone, we compared for 6 months 42 obese patients (32 least a five years follow-up.They were to be self-paying patients. f, 10 m) treated only with 1000 Cal diet (Group A) with 31 obese The transected silastic ring vertical banded gastric bypass was patients (24 f, 7 m) subjected to BIB + 1000 Cal diet (Group B). used. The patients were homogeneous for sex, age and weight.The Results:Fifty patients were entered into the study between two groups continued 1000 Cal per day diet for further 12 May 1st.1999 and Sep.30th 2000.Most of them were self-pay months. but there were some who were able to obtain coverage through Results:Mean weight loss was 14.5 kg (2-35); the mean their insurance companies.There were forty-eight women and reduction in BMI was 5.1 (0.3-11.2).Mean male weight loss was two men. There were no peri-operative complications nor 17.4 kg and female was 12.6 kg;the mean weight loss in obese deaths.The hospital stay was an average of 3.7 days.Follow-up patients with BMI > 40 was 16.4 and in those with BMI < 40 was has been from 9 months to 2 years.The weight loss has been 11.3 kg.The main complications observed were:balloon intol- excellent. erance with persistent vomiting and electrolyte unbalance:5%; Conclusion:Surgical intervention can be extended to patients insufficient weight loss (<10 kg):7.5%; BIB deflation:2.9%. The with BMI 32-40 without life threatening comorbidities but with comparison of group A with group B showed:at 6th month mean psycho-socioeconomic ramifications.Preliminary results are female group A weight loss was 11.9 kg (mean reduction of very promising.Long term follow-up and comparison to other BMI:4.7), mean male was 16.4 kg (mean reduction of BMI:5.6); bariatric patients are planned. in group B mean female weight loss was 15.5 kg (mean reduction of BMI:5.6) and mean male was 21.1 kg (mean reduction 131.TISSUE ADHESIVE FOR BARIATRIC SURGERY. of BMI:6.8). At 12th month group A female had mean weight Alan C. Roberts*, Stever Pollard*. *Academic Surgical Unit, loss:15.3 kg (mean reduction of BMI:6) and male had:19 kg University of Hull Medical School, England; **Department of (mean reduction of BMI: 6);group B female weight loss was Surgery, St.James’ s Hospital, Leeds, England 11.2 kg (mean reduction of BMI: 3.9) and male was 24.2 kg Background:Over a period of several centuries the union and (mean reduction of BMI:8). closure of human tissue has been achieved by means of needle Conclusion:1) the weight loss trend was much better in male and thread. Historically many types of suturing materials patients;2) the weight loss trend was much better in patients employed have met with varying success.Primarily there have with BMI > 40; 3) BIB + diet produced greater weight loss in been natural products such as cotton wool, fibre, linen and ani- shorter time vs.diet alone;4) BIB complications were poor and mal sinews.In modern surgical science synthetic materials such easy to cure;5) the most correct clinical indication for BIB ther- as nylon, dacron and various composites have gained impor- apy should be in morbidly male obese patients as preparatory tance.The culture and convention of wound closure by suturing treatment before bariatric surgery with the objective of reducing has been the standard method for generations of surgeons. unacceptable operative risk; 6) after BIB removal, bariatric During the past 25 years there has been a steady increase in surgery must occur as soon as possible;7) in patients with obe- interest in replacing and augmenting conventional sutures by sity-related complications before surgery; 8) in patients with adhesive bonds.There are several reasons for this clinical inter- severe cardiorespiratory alterations who will never be subjected est.First the potential rapidity with which tissue union can be to bariatric surgery but who must obtain a rapid, considerable achieved.Also the ability of bonding substrate to effect complete weight loss;9) in grade I obesity and in the overweight, only in tissue closure preventing seepage of body fluids.There is also

416 Obesity Surgery,11, 2001 Crete Abstracts an added advantage of forming bonds without deformation of The knowledge of risk factors as shown here should aid the the tissue.The possibility for improvement in the repair of tissue decision as to recommend a bariatric procedure to morbidly affected by age and disease and where suture methods are dif- obese patients. ficult and the ability to effect tissue closure in inaccessible areas of the body by laparoscopic surgery. 133.FOUR-YEAR EVALUATION OF THREE SURGICAL Methods:The surface phenomena found in novel formula- TECHNIQUES. tions of cyanoacrylates have shown considerable possibilities in R.Alvarez-Cordero, V.E.Aragón, R.J.Montoya, A.O Sandoval, surgical practice. D.A. Toledo. Hospital Angeles del Pedregal, Mé xico City, Results:The rapid polymerisation of these monomers when México. applied to moist tissue surfaces have shown the ability to bond In order to compare the long term evolution of three surgical human tissue effectively.They have also been found to act as techniques performed in our Clinic of Weight Control and fast and effective haemostatic agents and to achieve a mild Surgical Treatment of Obesity, this study was done by analyzing anaesthetic effect in topical application. the obese patient condition, weight, fat percent, comorbidities Conclusions :The development and use of tissue adhesive and quality of life, before surgery, and one, two, three and four synthesised in the laboratory presents an inventory sterile years after surgery .52 patients were operated of a reinforced adhesive with an effective use across the field of surgery . gastric bypass (OGBP), 45 had silastic ring gastroplasty (SRG), Cyanoacrylates have proved an effective sterile liquid suture and 47 gastric banding (LB).They all comply with the follow up system.Our experience of one N-butyl cyanoacrylate, Indermil, consultations, and most of them attended the support group will be described and its potential demonstrated in Bariatric meetings. Surgery. Patient’s condition:No hemodynamic or cardiopulmonary problems were noted in these series, regardless the patient’ s 132.CORRELATION BETWEEN FAT DISTRIBUTION, weight or the surgical technique used. HYPERLIPIDEMIA,DIABETES AND CORONARY HEART Excess weight loss:OGBP patients excess weigth loss was DISEASE IN MORBIDLY OBESE PATIENTS. between 20 and 75% on year 1, 24 and 90% year 2, 22 and Anna Maria Wolf, Burkhard Kortner, Hans Werner Kuhlmann, 100% year 3 and 18 and 86% year 4. SRG patients excess Ulrike Beisiegel *. General Surgery , Evangelisches und weight loss was between 14 and 56% year 1, 19 and 72% year Johanniter Klinikum Duisburg/Dinslaken/Oberhausen gGmbH, 2, 14 and 78% year 3, and 14 and 74 year 4.LB patients excess Germany, *Medical Clinic, University Hospital Hamburg- weight loss was between 12 and 60% year 1, 19 and 72 year 2, Eppendorf, Germany 15 and 100% year 3 and 18 and 83% year 4.These numbers It has been recognized that patients with a BMI < 40 kg/m 2 give an average of 42,68,73 and 72% for OGBP patients, 32, with excess abdominal visceral fat have more risk factors for 56, 66 and 62% for SRG patients, 38,60,68 and 69 for LB coronary heart disease than those with excess subcutaneous patients. abdominal fat.We were interested if these risk factors are the Fat percent:initial average fat percent was 62 for OGBP, 65 same for patients with a BMI > 40 kg/m 2.Performing bariatric for SRG and 60 for LB patients, they lose fat and had on aver- surgery on morbidly obese patients we had the opportunity to age:OGBP 58,50,36,35 on succesive years, SRG 59, 42,40,42, measure the subcutaneous fat layer.We differentiated between and LB 60,45,35,34.There was a correlation between excercise patients with excess subcutaneous abdominal fat and excess and fat percent improvement. abdominal visceral fat.A third group represented patients with a Comorbidities:High blood pressure:at four years, blood pres- combination of both. sure was normal in 14 out of 23 OGBP patients, in 11 out of 19 We divided our patients into females (n=318) and males SRG patients and in 15 out of 29 LB patients.The use of insulin (n=76) and analyzed the above mentioned three groups differ- or diabetes medication was discontinued in 16 out of 31 ently.Comparing males with excess abdominal visceral fat patients, 6 OGBP, 5 SRG and 4 LB patients;it was necessary to (n=52) with those who had a combined fat distribution (n=22) we continue the medication in 7,4 and 4 patients.Sleep apnea was found a significant effect on serum lipid levels. T riglycerides relieved in 4/8 OGBP patients, 3/8 SRG patients and 4/11 LB were significantly higher in patients with excess abdominal vis- patients. ceral fat (284 mg/ dl vs 197 mg/ dl, p=0.03) than those with a Quality of life:The evaluation at 1,2,3, and 4 years showed a combined abdominal fat distribution and HDL was lower (34 75 to 95 % degree of sastisfaction with the operation and the mg/dl vs 38 mg/dl, p=0.08).The lipid pattern of elevated triglyc- outcome, regardless the type of operation;changes in life style erides and low HDL is known to be a high risk factor for coro- (marriage, divorce, improvement on labor status, etc.) were nary heart disease.In female patients we did not see such a common high risk lipid profile but there are significant differences in BMI Conclusion:According to this study , it seems that OGBP and WHR. Female patients with excess abdominal visceral fat results in somewhat greater weight loss than the other tech- (n=62) have a higher BMI and WHR than those with excess sub- niques, even though this is not statistically significant.It seems cutaneous abdominal fat (n=31) as well as those with a combi- that these three techniques offer a good solution for severely nation of both (n=225). obese patient. In all patients with excess abdominal visceral fat leptin was found to be significantly lower than in the other two groups.This 134.FROM OPEN TO LAPAROSCOPIC GASTRIC BYPASS. difference in leptin does not correlate to differences in BMI.If we I.Díez del Val, C.Martí nez Blázquez, J.D. Sardó n Ramos, J.M. analyze the known risk factors in our patients we found a higher Vitores López, V.Sierra Esteban, J.Valencia Cortejoso. Hospital percentage of coronary heart disease and diabetes in patients Txagorritxu, Vitoria-Gasteiz, Spain with excess abdominal visceral fat.As to diabetes fasting glu- Background:From April 1996 to April 2001 248 patients suf- cose was only significantly higher in the females with excess fering from morbid obesity were operated on in our service. abdominal visceral fat (123 mg/dl vs 104 mg/dl, p=0,00007). Vertical banded gastroplasty has been definitively abandoned

Obesity Surgery,11, 2001 417 Crete Abstracts due to complications like linear stapler disruption, poor results No. Weight BMI in superobese and sweet eaters and bad quality of life.We pre- Surgery 25221kg (190 – 335kg)68 (54 – 99) sent our results with isolated gastric bypass (IGB) as primary 6 months25 179kg (148 – 225kg)55 (45 – 71) operation and our current progression towards laparoscopic 12 months20 161kg (128 – 212kg)49 (36 – 63) surgery. 24 months91 30kg (101 – 181kg)44 (29 – 54) Methods:Between February 1998 and April 2001, we have Six bands were removed - dysphagia after previous VBG 4; performed 188 IGBs, 166 of them as a primary procedure erosion 1;plateau weight 1.All were removed at > 24 months. (mean weight 125 kg [range, 75-214 kg] and mean BMI 47.84 All six patients were converted to a Scopinaro bypass which kg/m2 [range, 37.20-70.17 kg/m 2]).Our technique consists in the was done laparoscopically in two (the erosion and the plateau- creation of a small gastric pouch of 5 x 3 cm from the lesser cur- ing) and openly in four.There were two late deaths, both of them vature to the angle of His.A biliopancreatic limb of 40 to 200 cm occurring in patients who had the conversion to Scopinaro.One is performed depending on the preoperative BMI and a 70-cm occurred five years after surgery , weight having come from alimentary limb reaches the upper abdomen via a retrocolic, ret- 235kg to 105kg.At that time she had abdominoplasty and died rogastric way. An end-to-side anastomosis calibrated to the after a pulmonary embolus.The second patient who had severe internal diameter of the circular stapler (12mm) completes the cardiomyopathy prior to surgery , when she presented with a procedure.At the moment, this technique has been performed weight of 225 kg, died six months after Scopinaro bypass from by a laparoscopic approach in 22 patients with BMI <50. extension and deterioration of her cardiomyopathy. Results:Hospital mortality was nil and hospital morbidity Conclusion:Laparoscopic gastric banding with the ocurred in 10.2%, including 3 postoperative anastomotic leaks BioEnterics Lapband is a very effective tool in the management (1.8%) requiring laparotomy.Three patients had to be revised of the super obese.It can be inserted safely with minimal mor- surgically due to wound dehiscence (2 cases) and an incarcer- bidity and results in very satisfactory weight loss which is main- ated umbilical hernia (reoperation rate: 6/ 166=3.6%).Seven tained.Laparoscopic gastric banding is a very valuable tool in patients (4.2%) needed blood transfusion, probably as a conse- the care of the super obese. quence of an inadequate timing in low-mollecular weight heparin administra tion.No splenecto mies were required. 136.HOW CAN A NEW TECHNIQUE FOR LAPAROSCOPIC Wound infections were observed in 10 cases (6%).No compli- PLACEMENT OF THE ADJUSTABLE GASTRIC BAND (LAP- cations but a radiological fistula occurred in the laparoscopic BAND) PREVENT SLIPPEAGE ? series. D. Wagner, R. Weiner,* U. Winterberg, H. Bockhorn. During the follow up, 10 marginal ulcers were observed, 9 Chirurgische Klinik Krankenhaus Nordwest Frankfurt am Main incisional hernias (22,5%=9 out of 40 cases followed-up for >2 und Chirurgische Klinik Krankenhaus Sachsenhausen Frankfurt years) and four patients had to be reoperated because of symp- am Main*, Germany tomatic cholelithiasis (2), severe acid reflux and gastrogastric Background:Slippage (SP) of the stomach is the most com- fistula.The mean weight was 78 kg (range, 52-130) one year mon postoperative complication after laparoscopic adjustable after operation and 76 kg (45-125) at 2 years.BMI went down to silicone gastric banding(LASGB) for morbid obesity. 30,41 kg/m2 (20.83-42.69) and 29.6 (20.72-45.31) respectively. Methods:A randomized prospective study was constructed in The mean excess weight loss (EWL) was 72 and 75%. At 2 order to determine whether laparoscopic placement behind car- years, 96% of patients (53/55) maintained at least a 50% EWL. dia (RKP) is associated with lower incidence of postoperative Conclusion:Gastric bypass is a safe, effective procedure for (SP) and pouch dilatation than after a retrogastric placement most morbidly obese patients, with an acceptable rate of com- (RGP) of the LAP band using a common technique.Morbidly plications.In selected cases, laparoscopy may offer an impor- obese patients presenting for LASGB were randomized to tant reduction in abdominal wall and respiratory complications, undergo either an RKP (n=50) or an RGP (n=51). improving postoperative comfort and recovery. Results:There were three postoperative SP and three pouch dilations in the RGP group versus no postoperative complication 135.LAP AROSCOPIC GASTRIC BANDING FOR THE MAS- in the RKP group. SIVELY OBESE. Conclusions :The placement of LAP band by the RKP tech- George A Fielding. Wesley Hospital and Royal Brisbane nique is safe and followed by a lower frequency of postoperative Hospital, Brisbane, Australia comlications than with the RGP technique.Clear anatomical Background:To review the experience with laparoscopic gas- landmarks are a benefit to the education and learning curve of tric banding for the massive obese to determine its effective- LASGB. ness. Methods:Lapbands have been placed in twenty-five patients 137.INFLUENCE OF GASTRIC PERFORATION, SIMULTA- who had a weight over 190 kg, with an average weight of 221kg NEOUS CHOLECYSTECTOMY AND WOUND INFECTION ON (190-335kg).Average BMI 68 (54-99).There were five women LATE POSTOPERATIVE COMPLICATIONS. and twenty men with an average age of forty-six years (22-63). Christine Stroh, Haralad Schramm, Ulrich Hohmann. Wald- Six patients had had previous gastric stapling which had failed. Klinikum Gera gGmbH i.G. Departement fü r Allgemeine, Two massively obese patients with BMI’S of 99 and 91, weigh- Viscerale und Kinderchirurgie, Gera, Germany ing 335kg and 285kg were virtually bedridden. Background:Since the introduction of gastric banding in 1983 Results:The bands were inserted laparoscopically .Two it has been a proven method in the treatment of morbid obesity, patients had concurrent excision of massive abdominal pannus to reduce weight and maintain weight loss.We report about our with laparoscopic insertion of the band through the base of the experiences especially with a view of intra- and postoperative apronectomy wound.No intra-operative, in hospital or thirty day complications in connection with intraoperative complication like deaths and no deaths within three years of surgery.Weight loss gastric perforation, simultan cholecystectomy and wound infec- results are listed in Table. tion and late postoperative complications like band migration

418 Obesity Surgery,11, 2001 Crete Abstracts and infection of the port system. 139.MOTILITY DISORDERS OF THE ESOPHAGUS FOL- Methods:After the introduction of the technique in 1995 LOWING ADJUSTABLE GASTRIC BANDING OPERATIONS. about 150 were operated from February 1995 to June 1997 39 F.Schmoeller, G.Boehm*, K. Krichbaumer, M.Sengstbratl, patients were operated in the open technique.T o years later we R.Fuegger, F .Miess*. Elisabethinen Hospital Linz, Austria, started the operation of Gastric Banding laparoscopically.In the Department for Surgery, Department for Radiology* postoperative period occurred about 15% of complications.The Background:Pouch dilatation, band dislocation and band connection between complications and its cause like simultan migration are well known complications of ASGB-operations. operations, intra- and early postoperative complications should The very high position of the band close to the esophagogastric be analysed. junction ( pars flaccida technique) has been suggested to pre- Results:The weight loss occurs after 6 months 34.4% and 12 vent these problems. However, using the „ pars flaccida tech- month after gastric banding 46.9%.In about 15 5 of the patients nique“ there seems to be an important influence on esophageal a re-operation was necessary.The main indications for re-oper- motility in the long term.In order to evaluate the incidence of ations were slippage, pouchdilatation, disconnection of the motility disorders we performed a retrospective analysisis of all band system and complications of the port system.Rare com- our patients with ASGBs. plications were a stomach wall necrosis, a band migration and Methods:Between XII-1996 and III-2001 we implanted 237 port infections. The influence of intraoperative complications, ASGBs in pts.with morbid obesity laparoscopically.As we had simultane operations and postoperative complications like used the “perigastric”technique in the first 70 cases with a dis- wound infections to this complications should be detected. appointing high rate of band dislocation and pouch dilatation we Conclusions :A lot of complications especially after LASGB operated the following 167 pts.using the „pars flaccida“ tech- can be prevent if there is a strong indication and an exactly stan- nique.All pts.underwent fluoroscopic contrast swallowing stud- dardised laparoscopic technique is used without gastric perfo- ies during the band adjustment procedures.In case of clinical ration and wound infection.Conversions to the open technique symptoms ( dysphagia, obstruction symptoms , frequent vomit- were sometimes necessary during the learning curve of ing, inadeqate weight loss ) or pathological findings in the fluo- LASGB. roscopic swollowing study we peformed a videofluoroscopic swallowing study (VFSS). 138.IS A ROUTINE GASTROGRAFIN ® SWALLOW FOLLOW- Results:In 40pts.(16 .9%) we carried out VFSSs. In ING LAPAROSCOPIC GASTRIC BANDING MANDATORY? 6pts.(2.5%) we found an extreme transport delay of more more H.Nehoda, MD; K Hourmont, MD; R Mittermair, MD; M. than 30 seconds and in another 15pts.(6.3%) we found hypo- Lanthaler, T Sauper, MD;R. Peer*, MD;F Aigner, MD;H Weiss, motility of the esophagus ,10 of these pts. (4.2%) with MD. Department of General Surgery/ Department of Radiology* esophageal dilatation. In 2 pts. band removal was suggested University Hospital of Innsbruck/ Anichstrasse 35/ 6020 due to severe hypomotility and dilatation of the esophagus.In all Innsbruck/ Austria other patients conservative treatment with unfilling of the band Background:To assess the value of gastrografin swallow and diet was successful so far. (GS) as a method to detect postoperative complications after Conclusions :Motility disorders of the esophagus have to be adjustable laparoscopic gastric banding (ALGB) for the treat- considered as serious long term complications of ASGBs and ment of morbid obesity. might become more frequent indications for band removal in the Methods:From January 1996 to January 2001, 350 morbidly future. obese patients (295 women, 55 men) underwent a laparoscopic gastric banding operation.All data were prospectively collected 140.CONTROL AND REGRESSION OF TYPE II DIABETES in a computerized databank. All patients underwent a gastro- AFTER BARIATRIC SURGERY. grafin study in the early postoperative phase to exclude perfo- G. Vargas*, H.Cardoso*, M.Monteiro**, A.Sergio**, F.Pichel*, ration of the esophagus or stomach, which is one of the most M.J.Pereira I Santos***, C. Cunha***, F .Bravo***.Carvalho- serious complications occurring after the gastric banding oper- Santos***, H.Ramos*. Department of Endocrinology, Diabetes ation.Furthermore, the GS was performed to confirm band and Metabolism*; Surgery 2** and Clinical Chemistry***, San position and to exclude early pouch dilatation. Antonio General Hospital, Porto, Portugal Results:Out of the 350 ALGB operations, 6 (1.8%) early Background:Obesity, in particular visceral obesity is, besides pouch dilatations and 4 (1.2%) stomach perforations occurred. genetic predisposition, the strongest risk factor for the develop- All early pouch dilatations were recognized on postoperative GS ment of Type II diabetes.Sustained moderate weight loss can and immediately repaired laparoscopically.Of the perforations, improve glycaemic control.Bariatric surgery can be a solution one was recognized intraoperatively, and the other three were for severe forms of obesity principally if associated to complica- diagnosed postoperatively either by contrast media extravasa- tions such as diabetes. tion on the GS (two patients) or by computer tomography. Aim:to analyse the effects of weight loss after bariatric Conclusion:Presently, all patients undergo routine postoper- surgery in a group of severally obese and diabetic patients. ative gastrografin swallow, which exposes them to radiation, Methods:We analysed 10 super-obese diabetic patients (9 causes patient discomfort, and entails additional costs of women and 1 man) of medium age 45,6 years old (36-56), sub- approximately 100US$ per patient.Of the last 250 patients in mitted to gastroplasty between 1997 and 2001, with an average our series, there have not been any cases of early pouch dilata- follow up of 18 mouths (3-36).We analysed the evolution of the tion and since 1998 only one case of perforation has occurred, following parameters:weight, BMI, fasting glycaemia, insuline- which could be easily clinically suspected.Therefore, we believe mia, Peptide C and HbA1c;we also analysed lipid profile and that in experienced centers it is not necessary to perform rou- blood pressure. tine postoperative contrast media studies and recommend GS Results:the diagnosis of diabetes was stablished by fasting only in cases of complicated postoperative courses. glycaemia in 8 patients and by OGTT in the other 2.Six patients were receiving metformin, 1 metformin and sulphonylurea and 4

Obesity Surgery,11, 2001 419 Crete Abstracts only diet.After surgery there were significant improvements in developing diabetes mellitus, arterial hypertension, dyslipi- every parameters that we analysed.After an average follow up demia, obstructive sleep apnoea syndrome, degenerative of 18 mouths there was a weight reduction from 138.3 ±20 Kg changes in articulations with chronic pain, peripheral venous to 99 ±14 Kg (p<0.0001);BMI decreased from 52.8 ±8.5 Kg/m 2 insufficiency leading to oedemas of the legs and reproductive to 38,2 ±6,6 Kg/m2 (p<0,0001), fasting glycaemia reduced from changes such as hypogonadism in males and hyperandro- 185 ± 64 mg% to 98 ± 20 mg% (p=0,002), insulinemia genism in females.Many of these alterations can be improved decreased from 25 ±6.7 mU/ml to 16 ±7.3 mU/ml (ns), Peptide or even regressed by sustained weight loss. C decreased from 5.1 ±1.7 ng/ml to 3.3 ±0.7 ng/ml (ns) and Material and Methods :Eighteen patients, 16 females and 2 HbA1C improved from 8.4 ± 1.9% to 5.4 ± 0.7% (p=0.008). males, submitted to bariatric surgery where evaluated during 24 Seven patients are now normoglicaemic without antidiabetic months.Their average weight was 130 ±25.9 kg (91-194), with agents and the other 3 are still receiving metformin but gli- a BMI of 50 ±9.3 (36.5-76).Among the group there was 6% of caemic control substantially changed ( fasting glycaemia nor- diabetics, 29% of hipertense people, and 39% with obstructive malized and HbA1c decreased to 6.8;6.2; and 5.8%). sleep apnoea syndrome, 59% had peripheral oedemas, 47% Important improvements were also obtained in other compo- had arthralgia and 36% had urinary incontinence.Six of the 16 nents of metabolic syndrome that we analysed. women had policystic ovary syndrome and the 2 men had Conclusion:Bariatric surgery is an effective therapy for pro- hipogonadism.All were submitted to bariatric surgery for the ducing weight loss, leading to improvement and even normal- treatment of their obesity. ization of glycaemic control and of other disorders of metabolic Results:Twenty-four months after surgery the average weight syndrome such as dyslipoproteinemia and hypertension. This was 82.8 ± 15.4 (55-110), with a BMI of 32 ± 5.8 (24-41). would be expected to improve the long-term outcome for Among the group none has diabetes, arthralgias or peripheral patients. oedemas.Only 12% has hypertension but easily controlled with anti-hypertensive treatment. 6% still have sleep apnoea syn- 141.BEHAVIOR OF INSULIN RESIST ANCE AND LEPTIN drome and these patients are those who had the most severe LEVELS AFTER BARIATRIC SURGERY. forms pre-operatively. Urinary incontinence affects 6 % of the Bruno Geloneze, José Carlos Pareja, Enrico Repetto, Roberto female patients, and none presents policystic ovary syndrome. Teixeira, Silka Geloneze, Marcos Tambascia. UNICAMP, State One of the two males has normalized his testosterone levels. University of Campinas, Brazil Conclusions :Bariatric surgery is a means of treating effec- Background and aims :In obese subjects the circulating lev- tively not only the obesity but also the endocrine and metabolic els of leptin are elevated because the production and release of complications of the disease. leptin are directly related to adiposity .Weight reduction is followed by a reduction in leptin levels.The relationship between 143.REDUCING RISKS IN BARIATRIC SURGERY: IS SIBU- leptin and insulin resistance in obesity as well as their changes TRAMINE USEFUL? after massive weight loss are still controversial.The aim of this Enrico Repetto, Bruno Geloneze, José Carlos Pareja, Roberto study is to assess the association of leptin and insulin resis- Teixeira, Marcos T ambascia. UNICAMP-State University of tance in severe obesity patients after massive weight loss. Campinas, SP, Brazil Methods: Longitudinal clinical interventional study in 36 Backgrounds and aims :Superobesity is a clinical therapeutic severe obese patients underwent bariatric surgery (vertical gas- challenge, but bariatric surgery has been considered a conve- troplasty-Roux-en-Y gastric bypass) within one year follow-up. nient approach.Superobesity can cause metabolic abnormali- At baseline, 2, 4, 6 and 12 months after surgery serum leptin ties and increase operatory risks.There is a small experience was measured and insulin resistance estimated by insulin toler- using sibutramine in those patients.The aim of this study is to ance test (Kitt). evaluate the efficacy and the adverse effects of sibutramine in Results:BMI decreased from 56.2 ±9.4 to 35.6 ±6.7 kg/m?. superobese patients before undergoinf bariatric surgery. Leptin decreased and Kitt increased significant and linearly Methods:15 mg of sibutramine daily was given to 20 super- within follow-up (p<0.001), 78.8 ±30.0 to 17.9 ±11.5 ng/mL and obese subjects 3 months before surgery .Antropometric mea- 2.5 ±1.2 to 5.1 ±1.7 %/min, respectivally.There were a signifi- sures, abdominal circumference (AC), blood pressure (BP), cantly and positive correlation between leptin and Kitt during fol- heart rate (HR) and complains were evaluated at baseline and low-up (r= 0.64, p<0.001).Further adjustment to BMI caused a during 3 months. decrease in the strength of this association. Finally we found Results:The use of sibutramine induced a weight loss around that reduction in leptin was highly correlated to BMI than to 7% after three months treatment.It was well tolerate and no sig- insulin resistance. nificant adverse reactions occured baseline 1 month 2 months Conclusions :Leptin levels may be reduced after massive 3 months weight (kg) 153.7 ±23.6 147.9 ±23.5 146.0 ±23.7 weight loss in severely obese patients undergoing bariatric 143.1 ±23.5 BMI (kg/m 2) 57.5 ±6.2 55.3 ±6.3 54.6 ±6.2 53.6 surgery independently of the reduction in insulin resistance. ±6.3 AC ( cm) 146.1 ±14.8 138.2 ±14.4 systolic BP 144 ±11 142 ±12 140 ±13 139 ±12 dyastolic BP 98 ±9 97 ±9 97 ±9 142.IMPROVEMENT OF OBESITY-ASSOCIATED CO-MOR- 98 ±8 HR (bpm) 81 ±10 82 ±8 83 ±8 81 ±7. BIDITY AFTER BARIATRIC SURGERY FOLLOW-UP OF 18 Conclusions :Sibutramine using before bariatric surgery is a PATIENTS DURING 24 MONTHS. self and well tolerated treatment wich may reduce weight and Cardoso H., Monteiro M., Vargas G., S?rgio A., Pichel F ., operatory risks. Long term utilisation of sibutramine and its Pereira I.A, Santos M.J., Cunha C., Bravo F., Carvalho-Santos, metabolic changes in superobese patients is something wich Ramos H. Depts of Endocrinology , Diabetes and Metabolism, remains to be clarified. Surgery 2 and Clinical Chemistry, San Antonio General Hospital Port, Portugal 144.INSULIN RESISTANCE IN THE SEVERELY OBESE AND Background:Obesity is associated with increased risk of LINKS WITH METABOLIC CO-MORBIDITIES.

420 Obesity Surgery,11, 2001 Crete Abstracts

Richard S. Stubbs, Kusal Wickremes ekera. Wakefield obese and non-obese subjects.After a postoperative period of Gastroenterology Centre, Wellington, NZ median 282 days the BMI dropped significantly to 33.9 kg/m 2 Background:The association between insulin resistance (IR) (mean weight loss 32.9 kg). TNF a and ICAM levels were and obesity and its causal relationship with Type 2 diabetes is restored (p<0.05 versus preoperative), VCAM levels decreased well recognised.The possibility of an association, causal or oth- significantly (p<0.01) whereas neopterin and OLAB levels erwise, with other obesity related co-morbidities warrants con- remained unchanged. sideration. Conclusion:Morbid obesity is associated with impaired levels Methods:Insulin resistance was calculated pre-operatively in of immune-regulatory factors.Excessive weight reduction leads 80 patients undergoing gastric bypass surgery for severe obe- to normalization of these factors and thereby may improve sity (median BMI 44.5) using the Homeostasis model assess- immune-function and endothelial dysfunction. ment method and again on at least one occasion post-operatively within 12 months in 59 patients. Correlations with pre- 146.NORMAL ENOXAP ARIN DOSES GIVE TOO LOW existing co-morbidities, including diabetes, hypertension, dyslip- PLASMA VALUES IN MORBID OBESITY. idaemia, and hepatic steatosis and improvements in these fol- S.G. Frederiksen, L. Norgren, J. L.Hedenbro. Department of lowing surgery were made. Surgery, Lund University Hospital, Lund, Sweden Results:78/80 patients studied had insulin resistance pre- Background:Obesity is a risk factor for perioperative throm- operatively which did not correlate with pre-operative weight or boembolism.The risk of fatal pulmonary embolism in bariatric BMI.As expected there were positive correlations between IR surgery is estimated to be one in 2-300 patients. This is in and abnormal glucose tolerance and diabetes.A positive corre- accordance with our experience of three pulmonary emboli in lation was also found between IR and hepatic steatosis but no some 1.100 operations.This is despite compression stockings, correlation was noted between IR and hypertension or levels of early ambulation and prophylaxis with 40 mg enoxaparin cholesterol, triglycerides or Chol/HDL ratios although improve- (Klexane®) once daily.Specific studies on the prophylactic effi- ment in these did accompany improvement in IR after surgery. ciency in the obese are lacking. Improvement in IR was uniformly seen after gastric bypass and Methods:Nineteen patients scheduled for elective surgery sooner than would be accounted for by weight loss alone. (large bowel resection or obesity surgery) and BMI ranging from Degree of pre-operative IR was not a predictor of weight loss in 19 to 54 (kg/m 2) were given 40 mg enoxaparin subcutaneously this group of patients. 8 p.m.the night before surgery.Plasma samples were drawn at Conclusions :While insulin resistance is an almost universal baseline and hourly for the first six hours; thereafter bihourly accompaniment of severe obesity it is not closely correlated until at least ten hours post injection.Anti-factor Xa was deter- with the level of obesity.A number of important co-morbidities mined in plasma.For the individual curves thus generated, peak show a clear association with IR and improvement in these after plasma concentration and area under curve was calculated. gastric bypass may well be related to striking and rapid changes Results:Obese patients had a significantly lower peak in in IR. plasma concentration of anti- factor Xa.Area under curve (AUC) strongly correlated to BMI. 145.EFFECT OF EXCESSIVE WEIGHT LOSS ON IMMUNE- Conclusion:The recommended dosage of enoxaparin for REGULATORY MECHANISMS IN MORBIDLY OBESE high risk patients gives plasma concentrations that cannot be PATIENTS. expected to give the desired prophylactic effect in the morbidly H.Weiss, H.Schwelberger, J.Klocker, B.Labeck, H.Nehoda, F. obese.Controlled trials should be made with higher dosage, Aigner, G.Weiss. Departments of General Surgery and Internal and the effect on anti-factor Xa monitored. Medicine, University Hospital Innsbruck Background:The pathophysiological mechanisms that under- 147.SAFETY OF BILATERAL VAGUS NERVE STIMULATION lie the correlation between obesity and cardiovascular disease FOR OBESITY. are currently under investigation. An enhanced secretion of MS Roslin, M.Kurian, M Genovesi and F .Moody. Lenox Hill tumor necrosis factor-alpha (TNF a) and elevated levels of IL-6 Hospital, New York, NY , University of T exas at Houston, and C-reactive protein were discussed to trigger endothelial Houston, TX, USA dysfunction and activation of immune-regulatory mechanisms in Background:Results in canines have shown that chronic obese subjects.This study was performed assessing immune- bilateral vagus nerve stimulation (VNS™ ) may be a safe and activating factors in morbidly obese patients prior to and after effective treatment for morbid obesity.The purpose of this pilot excessive weight loss by means of adjustable gastric banding. program was to determine the safety of bilateral VNS in mor- Patients and Methods :40 morbidly obese patients (34 bidly obese patients. female, 6 male; mean BMI 44.7 kg/ m 2;mean age 37 years) Materials and Methods :From July 2001 to December 2001, underwent laparoscopic adjustable gastric banding (SAGB ®, six morbidly obese patients, mean BMI = 54.11 (range 40.71 to Obtech;06/ 1998-09/1999).Immune-regula tory factors and 71.11), mean age = 37.7 years (range 25 to 49) underwent adhesion molecules (neopterin, sTNFrecII, TNF a, ICAM-1, implantation of bilateral NeuroCybernetic Prosthesis (NCP ®) VCAM-1, OLAB) were determined according to standardized Systems (Cyberonics Inc;Houston, Texas) to the left and right procedures pre- and postoperatively.Eight healthy, non-obese vagus nerve trunks in the supradiaphragmatic position. NCP volunteers (mean age 33 years;mean BMI 22.6 kg/m 2) served Systems were activated 14 to 17 days after implantation. as control. Current was progressively increased from .25 to 4.5 mA at a fre- Results:Preoperatively serum levels of TNF a, sTNFrecII, and quency of 20 Hz and a pulse width of 500 µsec.Baseline blood ICAM-1 were significantly increased in morbidly obese patients tests, EKG, Holter monitor, and upper GI series were obtained compared to control subjects (p<0.01). However, levels of and repeated at 12 and 26 weeks after implantation. neopterin, VCAM-1 and OLAB, parameters of immune-regula- Results: No adverse events required discontinuation of VNS. tion and oxidative stress, did not reach significance between There were no occurrences of vasovagal symptoms, EKG

Obesity Surgery,11, 2001 421 Crete Abstracts change, pulmonary dysfunction, or gastrointestinal disturbance. every 2 weeks at the clinic until stable weight loss wasachieved. In one patient, output current was decreased secondary to pain The preoperative and postoperative complications, the number at higher currents.One wound infection was noted at the site of of fill up visits and the weight loss were recorded. NCP implantation.This same patient had VNS discontinued Results:Between October 1, 2000 and March 1, 2001 130 after 6 months because she became pregnant. patients were treated.64 patients received the Heliogast band Conclusions :This pilot study indicates that chronic bilateral and 66 received the Lapband.Both groups were comparable in stimulation is safe and well tolerated in morbidly obese adults. sex, age and weight distribution. There were no peroperative Longer follow-up and additional subjects are necessary to complications in either group.There were two immediate post- determine efficacy , optimal stimulation parameters, and ideal operative complications in group 1 (acute obstruction by fundus implantation technique. slippage through the band) vs no complications in group 2.Two patients in group 1 needed revision for port-tubing disconnec- 148.SURGICAL TREATMENT OF OBESITY BY GASTRIC tion vs zero in group 2.The Lapband patients needed three fill BANDING ups (1-6) vs five for the Heliogast (2-9).Puncture of the cham- Jean-Jacques Sala. Clinique Clément Drevon, Dijon, France ber was achieved by palpation in 50% of the cases with the Background:description of current methods with an analysis Lapband and in 80% of the cases with the Heliogast. Weight and review.Presentation of the complications of gastroplasties. loss per week was identical after three months in both groups Methods and Results :Early or late infections:these infections (1.3 kg).One patient in group 2 did not lose weight, probably are usually due to errors in asepsis during radiological follow up because of too large a size of the band. investigations.The complications are reduced if the people Conclusion:The reoperation rate of the Heliogast was signif- involved are aware of asepsis problems related to manipulating icantly lower with the Heliogast band. The Heliogast band is the implant. more difficult to puncture and needs more adjustments. The Complications associated with the band may be categorised as weight loss is identical in both groups. follows: - accidental opening of the band (<1%) 150.WEIGHT LOSS RESULTS OF VERTICAL BANDED GAS- - intra-gastric shift of the band.This may often be treated endo- TROPLASTY IN SUPEROBESE PATIENTS. scopically with subsequent repositioning of the band Yury I. Yashkov, Tatiana A. Oppel, Oleg G. Skipenko. Russian - slippage of the band Research Center of Surgery, Moscow, Russia Upward slippage: slippage may occur upwards (to the Background:Definite number of patients undergoing Vertical oesophageal position) and cause dysphagia.Revision surgery Banded Gastroplasty (VBG) lost inadequate weight to leave is required for this slippage or incorrect position.Downward slip- «morbidly obese» cohort. The aim of this study is to evaluate page (5 to 10% of cases):this is still the most common compli- whether predomination of superobese (SO) patients (BMI > 50 cation and causes gastric dilatation above the band.It is char- kg/m2) influences the results of VBG. acterised by pain associated with eating.A radiological follow up Methods:Among 67 patients undergoing Mason’s VBG since investigation is required if such pain develops. 1992 in our institution 38 (56,7 %) were SO (mean parameters Solutions:deflating the band and then re-inflating it a few are presented in the table1).We compared weight loss parame- weeks later;if pain persists, re-operation is required to remove ters between morbidly obese and SO patients at 1;1,5;2; 3; 4; or reposition the band depending on the gastric problems. 5 and more than 5 years after VBG. This is a genuine emergency as overly late intervention may AgeMale BMI BodyHeight Excess result in gastric resection because of perforation of the free peri- pts. (kg/m2)mass(cm) weight toneum. (%) (kg) (kg) Conclusion:an analysis of current statistics does not demon- Super strate any difference in morbidity between gastroplasty per- Obese formed by laparotomy or laparoscopy. There is, however, an (BMI>50)40.442.1 58.2 168.5 169.3 103.3 indisputable advantage associated with coelioscopic approach, n-38 which is less incapacitating and makes the process easily Morbidly reversible. Obese (BMI<50)41.617.2 44.5 122.5 165.7 60.5 149.HELIOGAST VS LAPBAND GASTROPLASTY. n-29 Jacques Himpens, Guido Leman. St Blasius Hospital, Results:In spite of more absolute (in kg) weight loss in the Dendermonde, Belgium SO patients % EWL did not differ significantly until the 3-rd year. Background:A new device was recently introduced for At 3-rd year and after 5-th year after VBG % EWL was less in adjustable silicone gastric banding (ASGB). This study was per- the SO cohort.No less than 40 % of SO patients in the each fol- formed to evaluate the value of this device in comparison to a low-up periods had BMI > 40 kg/ m 2, i.e remained morbidly well documented and widely applied device. obese.BMI in the SO group was higher in the each follow-up Methods:Our gastroplasty population consists of two groups: period.SO patients predominated among 20 % of patients who the locals and the foreigners. In an effort to evaluate the new had indications for revisional operations due to poor weight loss device all foreign patients were assigned to the well described after VBG. device (Lapband°, Bioenterics, Carpenteria, USA), group 1.All Conclusion:Results of VBG in terms of weight loss depend Belgian patients received the new device (Heliogast°), group 2. on worse results of SO cohort.Significant part of SO patients The operative technique was the same:pars flaccida approach, remain to be morbidly obese or even SO in spite of more burial of the band by several serosal stitches and fixation of the absolute weight loss. Since SO patients prevail among our band by a stitch from stomach to the eye of the band (group 1) bariatric patients we began performing vertical gastric bypass to and to one of the plastic lips (group 2).The patients were seen achieve better weight loss results.

422 Obesity Surgery,11, 2001 Crete Abstracts

Results:11 patients were followed up in periods between 1 151.VERTICAL BANDED GASTROPLASTY. A 12-YEAR and 3 years. The average weight obtained after the operation EXPERIENCE. was 82.3 (56-115 kg).The average weight loss after one year A.l.Papakonstantinou, P.Alfaras, V.Komessidou, J. Terzis, P . was 52.6kg ( 31-78kg) and the BMI average was reduced to Moustafelos, S.Gourgiotis, T .Anastasiou, E.Niakas, E. 32.5kg/m2 (25.3-45.2kg/m 2).In one case the ring was removed Mamplekou, E. Hadjiyannakis. 1st Surgical Department and after 2 weeks.Vomiting was reduced after 1-2 months.In one Transplantation Unit of the Gen.Hospital of Athens “EVANGE- case there was a haematom in the wound, 2 cases had infec- LISMOS”. Athens, Greece. tion and 2 cases eventration. There was no mortality .After a Aim of this study is to present and discuss the results and the year abdominoplasty was performed in 6 cases, underinginal complications of performing the Vertical Banded Gastroplasty and hip lipectomy in 3 cases. (VBG) for the treatment of morbid obesity in a 12-years follow Conclusion:The procedure is simple to be carried out.The up and propose some improvements on this technique for bet- results are excellent regarding weight loss.We had minor post- ter results. operative complications in 16 cases in comparison with compli- Methods:In this study 290 morbidly obese patients (226 cations mentioned by other authors:gastric haemorrhage,gas- female, 64 male) were participated that met two requirements: tric stenosis, dehiscence, underphrenic abcess. All the patients were regular to their follow up and had completed at least a postoperative period of two years. 153.MODIFIED VBG FOR MORBID OBESITY – AN EARLY Results:At the end of the first postoperative year 36.8% of INDIAN EXPERIENCE. males and 34.6% of females have reached normal weight (BMI Shrihari Dhorepatil, MD. Jahangir Hospital & Reaserch Center, 22-24) while 49.7% of females and 52.6% of males were near Pune,India. their normal BMI.At the end of the second postoperative year Background:There is a increased prevalence of obesity in our results improved:64.3% of females and 75.4% of males had India showed by NFI ,New Delhi report.This increase is pre- reached their normal weight, while 26.6% of females and 19.2% dominently seen in Indian Urban high income group popula- of males were near that goal.At the end of the third postopera- tion.The obesity surgery is recently introduced in last two years tive year appeared the first recurrences. T welve years after to treat morbid obesity in India.The procedure performed is application of this method the condition of our study group has Vertical Banded Gastroplasty. as follows:46.2% of females and 57.9% of males have reached Methods:Between Jan-1999 to April 2001, 36 patients of and remain their normal weight.15.8% of females and 17.5% of morbid obesity with BMI 35 kg/ m 2-72 kg/m2 , Mean BMI 42.5 males are near that.In 29.6% of females and 19.2% of males of kg./m2 were operated. (Weight range from 92 kgs.220 kgs. this study group recurrence of their obesity was observed. Mean Weight 120 kg).Modified Vertical Banded Gastroplasty Complications during this period were encountered as follows: was performed in all patients using TA 90 (Autosuture) Stapler pulmonary embolism in 6 patients (2.06%), pneumonia in 3 Results:No major complications, All patients had uneventful (1.03%), narrowing of the communicating lumen of the two parts post-operative period with minor complications & all of them of the stomach in five patients (1.7%), dehiscence of the verti- have started loosing weight from the 1st. post operative cal stomach staple line in 38 patients (13.10%), cholelithiasis in week.The weight loss was maximum in first 6 months but con- 18 patients, gastric perforation in four patients, postoperative fis- tinued for one & half year.The average weight loss at the end of tulas in four patients, significant gastritis and esophagitis in 32, one year was 70% of Extra Weight.Patients are satisfied with intestinal obstruction in five patients, hernia in 34 and frequent their small meals & changed dietary habit. prolonged vomiting in 23 patients. Conclusion:The morbid obesity is seen more in Indian Urban Conclusion:The strictest choice of the patients who were high income group population.MVBG is a relatively simple & submitted on this operation, the frequent and better psycholog- safe procedure with minimal side effects & low early morbidity & ical support and the more careful feeding of these patients dur- is effective in reducing weight with no early major complications ing the early postoperative period and the reinforcement of the & with high early patient compliance in Indian population. vertical suture of the stomach with another staple line are some improvements of the method for better results. 154.TEN YEARS OF EXPERIENCE ON VBG IN OPEN SURGERY. 152.VERTICAL BANDED GASTROPLASTY WITH SILICONE Stefano Cariani, D. Nottola, G.Vittimberga, S.Grani, A.Lucchi, RING: THE FIRST EXPERIENCE IN ROMANIA FOR THE F.Mancini, E.Amenta. Università di Bologna, Dipartimento di SURGICAL TREATMENT OF SEVERE OBESITY. Scienze Chierurgiche ed Anestesiologiche, Centro Studi di ter- Romeo Florin Galea, A.Ciule, D.Mircioiu, Dana Pintea, Florinela apia Chirurgica dell’Obesità Patologica ,Bologna, Italia Galea. The Second Surgical Clinic, UMF, Cluj-Napoca, Background:The treatment of morbid obesity with Vertical Romania Banded Gastroplasty (VBG) resulting in the decrease of food Background:The authors present the first 16 morbid obesity intake and seems to have lower risks and fewer side effects than cases operated on in Romania through vertical banded gastro- other procedures in patients having good compliance. Often plasty with silicon during 1997-2000. technical modifications concern: operation perfomed in open Methods:We used the TA 90 BNTM stapler with TA 90B tita- surgery or laparoscopy, stomach transection or not, the lenght nium cartridge following the Eckhout procedure.The pouch vol- of the vertical staple line, the length and the different kind of ume could not be always mesasured exactly.We always achived material of the band. Early complications as wound infection, the vertical direction from the Hiss angle.The gastric pouch cal- thrombophlebitis and pulmonary embolism are well-known. ibration was made with silicon ring 5-5, 2 cm.There were 9 Staple line disruption, pouch outlet obstruction, erosion of the women and 7 men of ages between 38-15 years.The average band and incisional hernias are described.In this report we pre- initial weight was 142,6 kg (95-167kg).The initial BMI average sent the results of 711 consecutive patients who underwent was 50.9 kg/m2 (43.7-63.7 kg/m 2). VBG.

Obesity Surgery,11, 2001 423 Crete Abstracts

Materials and Methods :Since 1991 VBG was performed in hospital stay , weight lost, co-morbidities resolution, early and open surgery with the technique as described by Mason, but in late complications, revisional surgery.We assessed the degree a standardized fashion as follows.We didn’t isolate the terminal of weight loss according to the Reinhold classification.Patient portion of the oesophagus and we devised an instrument follow-up has included:radiographic study of the stomach, phys- (Amenta-Cariani) to standardise the placement of the gastric ical evaluation and weight control at one month , six month and window (performed by using a 25 mm ILS ®-Ethicon Inc., every year postoperatively. Somerset, NJ, USA) and the pouch volume (about 30 cc). Results:Operative mortality was 0.3%.The mean operating Vertical gastroplasty was performed using T A-90B ® stapling time was 75 minutes and the mean length of hospital stay was device (Autosuture, US Surgical Inc., Norwalk, CT, USA). The 6 days.The mean EBWL% was 46% at 1 year, 48% at 2 years, pouch outlet with 11 mm tube inside is surrounded by a Gore- 47% at 3 years and 42% from 4 to 8 years.Early specific com- tex‘ band, of 15 mm wide and 0.6 mm thick and the length was plications were four (0.6%) and two gastric window bleeding calibrated on the thickness of the gastric wall not dissected to needed emergency operation.Late specific complications were vessels.From january 1991 to may 2000, 711 patients were 31 (4.5%) in 28 patients:we found staple line disruption (3.4%), operated, 112 were male and 599 female, the mean age was 38 pouch dilatation and outlet stenosis (1.2%).Revisional surgery years (range 16-69). The mean pre-operative B.M.I. was 46 was necessary in 27 patients (4.2%). kg/m2 (range 35-78), mean EBW% was 215% (range 147-354) Conclusion:In our experience, we can readily confirm that and 205 patients were classified as super obese (B.M.I.> VBG performed in open surgery gives good results again and is 50kg/m2).We have valued cost of operation, operational time, chosen as restrictive procedure. Posters

P1.OPTIMAL TIMING OF INCISIONAL HERNIA REPAIR Sérgio, M.J.Santos, C. Cunha, F.Bravo, Carvalho-Santos, H. AND LAPAROSCOPIC GASTRIC BANDING. Ramos. San Antonio General Hospital, Porto, Portugal H.Bonatti, W.Kirchmayr, H.Nehoda, F.Aigner, P.Kronberger, H. Background:Obesity is known to increase the degree of Weiss. Dept.of General Surgery, University Hospital, Innsbruck, insulin resistance and compensatory hyperinsulinism.As not all Austria tissues are as insulin resistant as others like muscle, liver or adi- Background:Obesity represents one of the most important pose tissue, some like the ovary retain the capacity to respond risk factors for perioperative complications and for recurrence of to insulin in a manner dose-dependent.The result is the exces- hernias.Bariatric surgery is associated with a moderate risk for sive production of androgens by the tecal cells leading to signs incisional hernia. This study was performed to develop strate- of hiperandrogenism, such as facial acne, hirsutism, anovula- gies for incisional hernia repair in morbidly obese patients. tion, menstrual irregularities and infertility .Weight loss, by Patients and Methods :Seven out of 392 (1.8%) patients (two reducing the hiperinsulinism can improve the signs of androgen men, five women: mean age of 51 years) underwent hernia excess and in some cases restore fertility. repair simultaneously with (two patients) or after (five patients) Material and Methods :Ten super-obese women with signs of laparoscopic implantation of a Swedish Adjustable Gastric Band hiperandrogenism were submitted to bariatric surgery (Swedish (SAGB®).Four of these hernias preexisted from previous Adjustable Gastric Band by laparoscopy) for treatment of their abdominal surgery at the time of bariatric procedure, one hernia obesity.Their mean weight was 149.3 kg (91-239) and mean developed following laparoscopic band placement after failed BMI 44.9 Kg/m 2 (41-77).All presented with menstrual irregular- open vertical banding at the median incision. ities, three had hirsutism and complained of infertility.On pelvic Results:Hernia repair was performed median 18.5 (range 0- ultrasound only three had policiystic ovaries and LH/ FSH> 3 51.5) months following SAGB implantation.Median BMI at the was found in only two of the patients. time of SAGB implantation was 44 (range 35-53).At the time of Results:After an average time of 19.2 months (9-36) post- hernia repair median weight loss was 38 (range 0-85) kg.In two operation, the average weight was 100.1Kg (61-167), with a patients hernia repair was simultaneously performed during BMI of 40.9 (26-63).All, except one patient, were menstruating abdominoplastic, in one patient simultaneously with SAGB regularly, and none had LH/ FSH>3.The three patients who change and in one patient a right subcostal incisional hernia complained of infertility attained spontaneous pregnancy and and a median lower laparotomy incisional hernia were repaired gave birth to normoponderal new born. simultaneously.Repair techniques included direct defect clo- Conclusions :Weight loss obtained through gastric banding sure (5 patients) as well as sublay prolene net implantation (2 (SAGB) in severe forms of obesity, led to the regression of clin- patients).There were uneventful recoveries without wound ical signs of hyperandrogenism and restored fertility. infections in all cases and no hernia recurrence after a median follow up of 2 (range 1-26) months.In two patients despite opti- P3.EFFECT OF MASSIVE WEIGHT LOSS IN GLUCOSE mal weight loss hernia repair had to be performed due to recur- TOLERANCE AND GHRELIN, A NOVEL GUT HORMONE. rent episodes of small bowel obstruction. Victor Pilla, José Carlos Pareja, Enrico Repetto, Bruno Conclusion:In morbidly obese patients, optimal management Geloneze, Silka Geloneze, Marcos Tambascia. UNICAMP-State and timing of incisional hernia repair should consider risk of University of Campinas, SP, Brazil. perioperative complications and recurrence as well as risk of Background:Ghrelin, an endogenous ligand for growth hor- hernia-associated complications. mone secretagoge receptor (GHS-Rs) , regulates pituitary growth hormone secretion.Pheriferic administration of Ghrelin P2.REGRESSION OF HIPERANDROGENISM IN OBESE caused weight gain in mice and rats. Intracerebroventricular FEMALES SUBMITED TO BARIATRIC SURGERY. administration of Ghrelin generates an increase in food intake H.Cardoso, M.Monteiro, G.Vargas, F.Pichel, I.A.Pereira, A. and body weight. Observing these interesting points and the

424 Obesity Surgery,11, 2001 Crete Abstracts possible interaction of Ghrelin in human obesity and metabo- brain peptide, is maintained blunted in severe obese patients lism, we performed a study concerning Ghrelin concentrations and correlates inversely to leptin levels. Differently that was in severe human obesity ranging from normal glucose tolerance hypothesised, ghrelin is not elevated in severe obese subjects to diabetes before and after massive weight reduction. and it is down-regulated in those subjects.These down- regula- Material and Methods :Longitudinal classical intervention tion may be a consequence of elevated levels of leptin and or study in 14 severely obese women (BMI=56.3 ± 10.2 kg/ m 2), insulin. classified according to glucose tolerance (8 normal- NGT group, and 6 type-2 diabetes- DM group), age: 32-55 years. Groups P5.TYPE-2 DIABETES, GLUCOSE CONTROL AND were mathec by age and BMI.Insulin, leptin and Ghrelin were INSULIN RESISTANCE FOLLOWING MASSIVE WEIGHT evaluat3ed by commercial RIA (LinCO for insulin and leptin, LOSS. Phoenix for Ghrelin) at baseline and 1 year after a vertical gas- Bruno Geloneze, José Carlos Pareja, Enrico Repetto, Silka troplasty and Roux-en Y by pass-( Capella”s procedure).Insulin Geloneze, Roberto T eixeira, Marcos T ambascia. UNICAMP- resistance were assessed by Homa model. Sate University of Campinas, SP, Brazil. Results:At baseline, there was a significant difference in Background:Bariatric surgery has been shown to be most Homa- ir betwenn groups (NGT= 14.3 ±3.2 x DM= 20.3 ±4.4, effective therapeutic approach for extreme obesity.Several stud- p<0.05), but not in insulin, leptin and Ghrelin levels. After ies have reported that surgery is able to improve the glucose surgery, we found a massive weight reduction similar in both control.It is noteworthy that bariatric surgery allows the supres- groups (final BMI= 36.2 ± 7.8 kg/ m 2, p<0.01).Homa-ir had a sion or, at least, drastic reduction of antidiabetic drugs.The rela- marked reduction after surgery in NGT (3.0 ±2.1, p<0.01), as tionship of glucose control and insulin sensitivity in those well in DM (2.8 ±0.8, p<0.01), being both froups with similar patients is poorly investigated. Homa-ir at 1 year follow up.Insulin decreased in NGT from 44 Materials and Methods :We followed up 10 type-2 diabetic ±7.7 to 14.7 ±3.8 uU/ml (p<0.01), and in the DM group from patients undergone vertical gastroplasty with Roux-en-Y bypass 59.4 ±12.8 to 15.5 ±10.7uU/ml-( p<0.01).Leptin decreased in within one year, observing their glycemic control and insulin NGT from 74.5 ±24.9 to 20.9 ±13.2 ng/ml (p<0.01).Ghrelin did sensitivity estimated by an insulin tolerance test (ITT) performed not show any difference between groups and did not change initially, 6 and 12 months after surgery. after weight reduction (NGT: 21.3 ±6.7 to 29.4 ±4.9 pg/ml, and Results:A massive reduction of 70% in the initial excess body DM:27.7 ±4.9 to 24.0 ±2.3).Univariate regression analysis did weight was achieved one year after surgery.The insulin sensi- not show correlation between Ghrelin and other parameters. tivity index (KITT) showed a significant increase during the fol- Conclusions :Ghrelin was not affected by glucose tolerance low up period (r= 0.53, p< 0.01).We observed a strong linear status nor by weight changes in severely obese women.Despite correlation between KITT and glucose levels (r= -0.50, p<0.01), that, the role of this hormone in human obesity, food intake reg- and with HbA1C (r= -0.51, p<0.01).This metabolic improvement ulation and weight changes remains to be clarified. was observed despite an impressive interruption of any phar- macological treatment of diabetes within one year follow up. P4.RELA TIONSHIP BETWEEN GHRELIN AND LEPTIN IN Baseline 6 mo.12 mo.BMI (kg/m 2) 54.1 ±8.7 40.6 ±7.6 35.5 ± OBESE SUBJECTS. 6.1 Glucose (mMol) 10.8 ±4.9 5.7 ±1.3 4.6 ±0.5 HbA1C (%) José Carlos Pareja, Victor Pilla, Bruno Geloneze, Enrico 7.6 ±2.2 4.9 ±0.3 4.6 ±0.7 KITT(%min) 1.65 ±1.02 3.76 ±1.65 Repetto, Silka Geloneze, Marcos Tambascia. UNICAMP- State 4.43 ±2.34. University of Campinas SP, Brazil Conclusions :Weight loss is a major target in treatment of Background:Ghrelin, a novel gut-brain peptide, acts in the obese patients with type-2 diabetes.In this group the remark- regulation of growth hormone secretion.As it was isolated from able weight reduction was effective on improving glycemic con- the stomach both in rodents as well as in humans there are evi- trol.This effect on glucose metabolism is due to a significant dence of its participation also in energy metabolism. Ghrelin increase in insulin sensitivity observed in this population. gene expression was increased by fasting and decreased by leptin.Human obesity has been considered as a leptin resis- P6.INFLAMMA TORY MARKERS, INSULIN RESISTANCE tance state as serum levels are elevated in obesity matched by AND WEIGHT LOSS FOLLOWING BARIATRIC SURGERY. body mass index.The aim of this study is to verify the relation- Bruno Geloneze, José Carlos Pareja, Enrico Repetto, Roberto ship of ghrelin and leptin in a wide variation of BMI in humans Teixeira, Silka Geloneze, Marcos Tambascia. UNICAMP–State and to study the possible relationship of ghrelin-an adipogenic University of Campinas, SP, Brazil hormone- in the pathogenesis of severe obesity. Background:Obesity has been described as a inflammatory Materials and Methods :We studied 14 severe obese patients state.Some markers of this condition are elevated in obesity and 14 normal controls. Ghrelin was measured by radioim- such as fibrynogen, coagulation factors, C-reactive protein and munoassay using a commercial kit provided by Phoenix. white blood cells count (WBC).The relationship between WBC Intraassay variation coefficient was 13.3%.Leptin was analysed and insulin resistance, as well as the effect of weight reduction using a kit provided by Linco Co wiyh an intraassay variation of in this relation are still controversial.The aim of this study is to 10,5%.Insulin was analysed by RIA using a kit by Linco Co. assess the association of white blood count and insulin resis- Results:Normal controls have BMI of 24.2 ±1.5 kg/m 2, leptin tance in severe obesity before and after massive weight loss. levels were 7.0 ±3.9 ng/ ml, ghrelin of 67,1 ± 11.9 pg/ml and Methods:Longitudinal clinical interventional study in 46 insulin levels were 10.5 ±2.5 uU/ml.The severe obese patients severe obese patients submitted to a bariatric surgery (vertical have BMI of 56.3 ±10.2, leptin of 80.2 ±30.2, ghrelin of 23.2 ± gastroplasty Roux-en-Y gastric bypass) within one year follow- 6.7 and insulin levels of 37.5 ±18 uU/ml.Univariate regression up.At baseline, 2, 4, 6 and 12 months after surgery white blood analysis showed a negative correlation of ghrelin and leptin, r= county was measured and insulin resistance estimated by -0.51 (p< 0.01). HOMA. Conclusions :We observed in this study that ghrelin, a gut- Results:BMI decreased from 54.5 ±8.9 to 34.5 ±6.3 kg/m 2.

Obesity Surgery,11, 2001 425 Crete Abstracts

WBC acid and HOMA-IR decreased significant and linearly Scopinaro (181).Indications-previous obesity surgery (VBG, within follow-up (p<0.001), 9.2 ±2.0 to 6.5 ±1.7 mg/L and 16.8 rigid bands) 35;dysphagia after lapband 37;eroded bands 4;by ±12.0 to 3.0 ±1.4, respectivelly.There were a significantly and choice 21, public hospital availability 84. Weight 148kg (72- positive correlation between WBC and HOMA-IR in basal state 255kg);BMI 45 (29-85);mortality 0;hospital stay-open 9 days, (r= 0.37, p<0.05), and during follow-up (r= 0.36, p<0.05). laparoscopic 5 days.Complications-leak 6;PE 1. Conclusions :An important determinant of the WBC in severe Conclusion:The ease of lapband, rapid return to normal obese patients before and after reduction was the insulin resis- activity and lack of bowel complications make it the author’s first tance index.Thus WBC could be a component of insulin resis- choice.BPDDS (laparoscopic) is a great alternative and excel- tance state and may be reduced after massive weight loss, pos- lent fallback position in the 6% who do poorly with lapband. sible indicating a reduction in inflammatory associated condition. P9.LAP AROSCOPIC ADJUSTABLE GASTRIC BANDING IN SUPER-MORBID OBESE: AN EGYPTIAN EXPERIENCE. P7.INSULIN RESIST ANCE AND URICEMIA IN SEVERE Hany Aly Nowara, MD, FRCS. Cairo University Hospital and OBESE SUBJECTS FOLLOWING BARIATRIC SURGERY. Mokattam Surgery Center, Egypt Bruno Geloneze, José Carlos Pareja, Enrico Repetto, Silka Background:Gastric banding is now widely practiced for Geloneze S, Marcos Tambascia. UNICAMP–State University of management of morbid obesity. Doubts have existed over its Campinas, SP, Brazil role in treatment of Super-morbid obese. The purpose of this Backgrounds :Hyperuricemia is associated with components study is to assess the results of gastric banding in 136 patients of metabolic syndrome as hyperlipidemia, impaired glucose tol- with BMI above 50 Kg/m 2. erance, hypertension and obesity .The relationship between Methods:136 super-morbidly obese patients having a body serum uric acid and insulin resistance, as well as the effect of mass index (BMI) >50 hg/ m 2 were included in this study .56 weight reduction in this relation are still controversial.The aim of patients had a BMI above 60 Kg/ m 2.The procedure was per- this study is to assess the association of hyperuricemia and formed through a 4 or 5 trocar technique.Pneumoperitoneum insulin resistance in severe obesity after massive weight loss. and first trocar insertion were done via the open method.T wo Methods:Longitudinal clinical interventional study in 48 insuflators were used with extralong instrumen ts. severe obese patients submitted to a bariatric surgery (vertical Endoillumination of the esophagus was done in all cases gastroplasty Roux-en-Y gastric bypass) within one year follow- Results:The mean age of the patients was 41.3 years.The up.At baseline, 6 and 12 months after surgery serum uric acid mean BMI was 59.1 Kg/m 2.All procedures were completed by level was measured and insulin resistance estimated by HOMA laparoscopy.The mean hospital stay was 3.2 days.The mean (HOMA-IR index). BMI after 12 months was 44.2 kg/ m 2 & after 24 months was Results:BMI decreased from 54.5 ±8.9 to 34.5 ±6.3 kg/m 2. 34.2 kg/m2.The mean follow-up was 26 months (6-48).There Uric acid and HOMA-IR decreased significant and linearly were no mortalities in this series . within follow-up (p<0.001), 6.9 ±4.5 to 4.8 ±1.4 mg/L and 15.4 Conclusions :laparoscopic insertion of the adjustable gastric ±12.1 to 2.9 ±1.5, respectivelly.There were a significantly and band proved to be suitable for superobese.Gastric banding is a positive correlation between uric acid and HOMA-IR in basal safe and effective method for the treatment of super morbid state (r= 0.37, p<0.01), and during follow-up (r= 0.51, p<0.001). obesity in Egyptian patients. Further adjustment to BMI caused a decrease in the strength of this associatio n, however the influence of BMI variation P10.BARIATRIC SURGERY FOR CHILDREN AND ADOLES- appeared to be weaker than HOMA-IR reduction. CENTS: WHAT ARE THE INDICATIONS? Conclusions :The major determinant of the serum uric acid Khaled Gawdat, MD, Ashraf Kabesh, MD. Ain Shams School of levels in severe obese patients following weight reduction was Medicine, Cairo Egypt. the insulin resistance state. Thus uric acid levels may be Background:Eighteen years of age is the minimum accepted reduced after massive weight loss due to reduction in insulin age for bariatric surgery.Some times morbid obesity affects chil- resistance. dren and adolescents who may need bariatric surgery at a younger age.We present our results of bariatric surgery in this P8.INTEGRA TED SURGICAL APPROACH TO OBESITY. age group. George A Fielding. Wesley Hospital and Royal Brisbane Methods:29 morbidly obese of age <18 years old received a Hospital, Brisbane, Australia. bariatric surgical procedure with a mean follow up period of 16.9 Background:This paper reviews result of an integrated man- months (3-42 months).The mean age was 15.9 years old (9-18 agement plan for morbidly obese patients, combiding Lapband years).The mean weight was 144.6 kg (97-250 kg) with a mean and Laparoscopic Scopinaro Bypass, to assess the place of BMI of 53.8kg/ m 2 (40.1-77.2 kg/ m 2) and the mean EBW was both in one practise. 85.5 kg (45.8-178.7kg).19 patients had vertical banded gastro- Methods:Since February 1996 lapband has been used (895) plasty (VBG), 3 patients had laparoscopic adjustable gastric for morbid obesity .In July 1998 Scopinaro Bypass was com- banding (LAGB) and 7 patients had Roux-en Y gastric bypass menced and has been done laparoscopically since August (RYGB). The reason for interfering at <10 years of age was 1999.T otal 181 - 109 laparoscopic (76 with BPDDS and sleeve severe skeletal deformity together with super-obesity.82.7% of gastrectomy). the patients had a BMI >50 kg/ m 2.31% had hypertension, Results:Lapband (895).Three converted to open-one death 17.2% had respiratory insufficiency , 3.4% had gall stones, (perforated duodenal ulcer);hospital stay 1.8 days (1-9);weight 51.7% had joint problems, 10.3% had severe skeletal deformi- 142kg (85– 365kg); BMI 47 (34– 99). At three years BMI 27. ties interfering with walking, 58.6% had chronic back problems. Weight loss maintained at 4.5 years in first fifty cases. 70% of the female patients had menstrual troubles. Complication-erosion 4;slip 62 (8 in last 415 since changing to Results:Hospital stay was a mean of 4.86 days. posterior approach);dysphagia needing removal 39. Postoperative complications: No mortality, 2 patients had GIT

426 Obesity Surgery,11, 2001 Crete Abstracts leakage, 5 patients had wound infection, 1 patient had incisional warned of the rare complication of acute gastric ischaemia due hernia.Patients lost a mean of 60.2% of their excess body to strangulation with the slip. weight 12 months after surgery.At 24 months after surgery the mean excess body weight loss dropped to 54.3%. P13.THE EFFECTS OF LONG LIMB GASTRIC BYPASS ON Hypertension was cured in 100% of the patients, menstrual MONOCYTE DYSFUNCTION IN MORBID OBESITY. problems were corrected in 85% of the patients and ambulation L.D. G.Angus, MD, D. R.Cottam, MD , D. Fahmy, MD, G.W. was improved in all of the patients. Shaftan, MD, P .A.Schaefer, PhD. Nassau University Medical Conclusion:Bariatric surgery can be utilized at younger ages Center, Department of Surgery East Meadow, New York, USA if super obesity is present especially in the presence of skeletal Background:There is a large body of epidemiological data deformities.Out come of surgery in this patient group was sim- associating obesity with various cancers and wound infections. ilar to the outcome in the adult population but longer follow up is However, information on the monocyte role in the immune func- necessary to confirm this finding. tion of obesity has been lacking. We investigated several cell surface antigens on monocytes and followed their response to P11.THE EV ALUATION OF ETIOLOGY,RISK FACTORS , surgically induced weight loss. COMPLICATIONS AND BENEFIT,USING THE DA TA BASE Methods:Twenty-seven patients having gastric bypass “OBESITY 2.0”FOR LAPAROSCOPIC BARIATRIC surgery for obesity (BMI>40) were compared to 10 normal con- SURGERY. trols (BMI<26).Relative monocyte frequencies and expression D.Wagner, R.Weiner,U.Winterberg, H.Bockhorn. Department of the activation antigens CD11b (integrin adhesion molecule), of surgery, KH Nordwest, Frankfurt a.M., Germany CD 14 (LPS receptor), CD16 (Fc receptor), CD14/CD16 subset Background:The complex data of obese patientsundergoing (inflammation parameter), and CD62L (L-selectin, adhesion bariatric surgery had to be documente d and evaluated. molecule), were evaluated by flow cytometry .Additionally cell Therefore a system-software will benecessary. counts were made. Methods:On the base of FileMaker Pro programm a data Results:The study control group had a mean age of 37 ±7.6 base for patients before and after laparoscopic gastricbanding (range 30 to 57) with no significant health problems.Their mean was developped.The programm works with Windowsand Mac. body mass index (BMI) was 23 ±2.5 (range 21-26).The mean All data, which were important to select patients for bariatric age of the sample group was 40.36 ±13.7 (range 18 to 60) with surgery were included. a mean BMI of 52 ±8.2 (range 41 to 72).The relative monocyte Results:The etiology, risk factors, patient history and the frequencies in the obese patients were statistically similar to postoperative follow-up of 1287 patients were documented in controls throughout the study period. Likewise CD11b and the data base. The import and export of files into other pro- CD16 did not differ from controls throughout the three-month gramms is easy to perform. Statistical analysis can be per- study.A significant reduction of CD62L (L-selectin) expression formed by means of EXCEL and other programms.The data- was noted in the morbidly obese with respect to controls (gmf transfer by internet isusefull. 104 vs. 246, p= <0.001). There was an inverse relationship Conclusions :The data base “Obesity 2.0”allows acomplex between elevation of BMI and depression of L-selectin using registry, selection and follow-up of patientsundergoing bariatric pearson’s correlation at baseline (p=0.037). This depression surgery.The system can beestablished and used very easily. continued through one month but by three month there was not a statistical difference (gmf 203 vs.246, p=0.3).The LPS recep- P12.LAP-BAND PERSISTING GOOD RESULT WITH tor molecule CD14 was significantly elevated in comparison to SLIPPED BAND BY MODIFIED TECHNIQUE. normals (gmf 1129 vs.658, p=0.022).This difference continued George A Fielding. Wesley Hospital and Royal Brisbane through the first month post operatively.Yet, by the third month Hospital, Brisbane, Australia this difference had disappeared statistically (gmf 809 vs.658, Background:Slip has been the major problem with lapband p=0.312).The last variable studied was CD14/CD16 subset per- surgery.Eight hundred and ninety five bands have been percentages.The levels of this were statistically elevated through- formed by the author since February 1996. out the three month study period when compared to controls, Methods:In the first 480 cases performed up to December but declined with weight loss, median values preoperatively 1998, prior to change in technique, there have been 54 slips were 14 (25%= 11.5, 75%= 16.00, p=0.004), 12.8 at one month (12%).These occurred at 11 months (4– 52) after surgery .All (25%=10.75, 75%=17, p=0.007), and at three months 11.1 presented with reflux, dysphagia to solids and often asthma.All (25%=9.4, 75%=16.6, p=0.036). bands were repositioned.T en went on to Scopinaro Bypass due Conclusion:Discordant CD11b/ CD62 levels with elevated to persistent dysphagia. Due to this problem, the author CD14 and CD14/ CD16 subset percentages suggest that a changed to a posterior approach, going through the lesser chronic inflammatory and chronic immuno-deficient state exists omentum, behind the O-G junction, above the lesser sac.There in the monocytes of morbidly obese patients.Additionally , our is a small anterior pouch with gastro-gastric suturing over the finding of reduced expression of CD62 suggests a pronounced band anteriorly. impairment exists in the monocytes’ability to migrate to sites of Results:In the thirty months since December 1998 there inflammation.This dysfunction is reversible with gastric bypass. have been 415 bands inserted with the new technique. There have been 9 slips (2%).These occurred at 10 months (6-14). P14.ABNORMAL VIDEOFLUOROSCOPIC FINDINGS IN Two have had acute slips with ischaemia of the stomach fundus PATIENTS AFTER LAPAROSCOPIC GASTRIC BANDING. characterised by extreme pain. One presented late and died G. Boehm1, F .Schmoeller 2, K.Kriechbaumer 2, F. Miess1, R. with peritonitis.Three have had the band removed and conver- Függer2. 1Department of Radiology , Elisabethinen Hospital sion to laparoscopic BPDDS. Linz, Austria 2Department of Surgery , Elisabethinen Hospital Conclusion:The incidence of slip is greatly reduced by the Linz, Austria posterior approach via the lesser omentum.Patients should be Background:To evaluate the frequency of morphological and

Obesity Surgery,11, 2001 427 Crete Abstracts functional disorders of the esophagus in videofluoroscopic swal- up thoroughly, to introduce small morsels of food and prolong lowing studies (VFSS) of patients with morbid obesity treated the mastication time, to avoid dysphagia. with laparoscopic adjustable gastric banding more than one In conclusion, we can affirm that esophago-cardiasic banding year before. gives no problem if well positioned; promotes new alimentary Methods:We carried out 40 VFSS in patients after Gastric habits through a dysphagic mechanism, inducing this way a sig- (11) and Esophagogastric (29) Banding who had been operated nificant BMI and excess weight reduction. between 1998 and 2000. 39 female pts. and 1 male pt. were examinated VFSS was performed with a standard protocol and P16.APOLIPOPROTEIN E AND CIII IN PATIENTS WITH OBE- in addition plain films were made.The clinical criteria to make a SITY-RELATED PHENOTYPE BMI AFTER BARIATRIC VFSS were: dysphagia, obstruction symptoms, inadequate SURGERY. weight loss, increase of vomiting, inadequate transport of con- J.C.Cagigas*, Alfredo Ingelmo*, R. Hernandez-Estefania, D. trast agent in normal fluoroscopy usually done by the surgeon. Gonzalez-Lamuño, M.Garcia-Ribes, S.Revuelta*, C. Escalante According to the clinical symptoms the radiological criteria Nutrition and Cardiovascular Risk Unit. University of Cantabria; were:position of the band, presence of a pouch, esophageal General Surgery .Hospital Universitary Valdecilla, Hospital dilatation (normal £ 4cm), transport delay (10 ml Barium- Sierrallana*, Spain. Suspension <10 sec.) and propulsive contractions of the esoph- Background:Recent research on obesity has revealed that agus. body weight is in fact a truly complex phenotype.Body weight is Results:In 40 pts.35 morphological and dynamic findings in influenced by any factor that influences the weight of any indi- 25 pts.(62.5%) could be depicted including:4 dislocated bands, vidual tissue, organ, or fluid.We analyses the influence among 6 pts.with an extreme transport delay (more than 30 sec.), 15 the obesity-related phenotype BMI after bariatric surgery and pts.with a conspicuous hypomotility of the esophagus followed genetics polimorphs E and CIII. in 10 pts.by an esophageal dilatation. Methods:54 patients were treated by vertical banded gastro- Conclusion:Functional impairment of the esophagus seems plasty (VBG). All patients were women with a mean age of 35.4 to be frequent in patients after LAGB.If morphological abnor- (range 20-46) years.Mean body-weight was 128kgs.(105-146) malities are absent , the diagnosis of dynamic disorders should and mean BMI was 49.58 (35.6-53), before surgery.Others 135 be considered. VFSS is a radiological method to reveal func- patients were control group (N) with 110 women.Study of the tional and morphological abnormalities in patients after laparo- genetics polimorphs apolipoproteins:Apo E, Apo CIII were per- scopic gastric banding as a treatment of morbid obesity. formed with techinques of specific digestion with restriction´ s enzyme and PCR reactions-termociclator.Analysis statistics P15.ESOPHAGO-GASTRIC LAPAROSCOPIC PLACEMENT were t of Student, Mann Whitney, odds ratio and statistic pro- OF LAP-BAND FOR MORBID OBESITY: CONSIDERATIONS gramm V.2 AFTER THE FIRST 80 CASES. Results:The relative prevalences for the polimorph Sergio Boschi, L. Fogli, A. Cuppini*, M. Brulatti, P .Patrizi, V . apolipoprotein E of the alelos e2, e3, e4 (group VBG) were 0.06, Papa, M. Di Domenico, F .D.Capizzi. General Surgery and 0.84, 0.1 respectively .No have any differences between gen- *Internal Medicine, Bellaria Hospital, Bologna, Italy ders.Only was founded four of the total six feasible genotypes Laparoscopic gastric banding is an effective surgical method influenced for the tree alelos linkaged apolipoprotein E as it was for the treatment of morbid obesity, but is fraught with specific not founded any patient e2/ e2 ni e2/ e4.Similar prevalences complications, like slippage and gastric erosions.T o reduce the (e2=0.04;e3=0.87; e4=0.09), were in group control (N). The incidence of such complications, several technical variants have genotype E4/ E3 was presented more decrease in cholesterol been used, including high retro-gastric positioning, above the than E3/ E3:p=0.0024.The relative prevalences for polimorph bursa omentalis, complete anterior fixation through gastro-gas- apolipoprotein CIII with 2 alelos genotypes S1/ S2 were 0.95/ tric stitches around the lapband, reduction of the gastric pouch 0.05 in the obese patients respectively.No differences in group volume to 15 ml or less. N (S1=0.94;S2=0.06). In relation to the asociation of unbalance These technical variants end up inducing dysphagia. The among the presence of isomorph S2 from gen of the technique adopted by us, consisting in placement of the pros- apolipoprotein CIII and mutations that relation to the gold thesis around the esophagus , 2 cm above the gastro- sequence for the insulin in the región promoter of the same gen, esophageal junction, is aimed at inducing an amplification of was noticed that all patients with alelo S2 showed at least one this mechanism.No fixation of the gastric wall is needed.Since of the two mutations described – 482;-455. The patients with January 1999, 80 consecutive patients have been operated on genetic polimorph Apo E and genotype E4/E3 showed mean of laparoscopically this way, using the 9.75 cm Bioenterics ® cholesterol was 204.8 mg/ dl, more elevated than genotype Lapband. E3/E3 (193 mg/dl) before surgery. Complications include two cases of slippage: an early one, Conclusions :In our population, the polimorph S2 for apoCIII after 24 h, requiring surgical removal, and a late one, after 9 is associated with a mutation in one region of the gen over feed- months, treated by laparoscopic re-positioning.In both cases, a back insulin.No have any association with diabetes or glucose small part of the gastric wall was accidentally included within alteraded with genotype S1/S2.The morbid obese patients pre- the lapband. In another case, a reactive esophageal stenosis sent more decrease of levels of cholesterol with the presence of occurred in a trans-sexual male patient under estrogen hor- isomorph E for apoprotein E (group E4/E3, p=0.022), 6 months monal treatment:substitution with a wider Swedish lapband was after vertical banded gastroplasty. needed.No more complications have been registered. Patient compliance has been good, and results of BMI and excess P17.OBESITY SURGERY PITFALLS AND MORBIDITY A T weight reduction (42% and 50%, respectively after one and two 10-YEAR FOLLOW-UP WITH VERTICAL BANDED GASTRO- years) have been noteworthy.The technique here descibed has PLASTY. a re-educational function, in that patients are induced to chew J.C.Cagigas*, Alfredo Ingelmo*, R. Hernandez-Estefanía, F .

428 Obesity Surgery,11, 2001 Crete Abstracts

Olmedo, S. Revuelta*, E. Martino, C.F .Escalante. Hospital or perforation. Valdecilla. Hospital Sierrallana*, University of Cantabria, Spain. Obstruction of the biliary limb of the RYGB, by definition, con- Background :Vertical banded gastroplasty (VBG) has proven stitutes a “closed loop”. Because of the unique anatomy of the itself an efficient bariatric procedure in morbidly obese patients, upper gastrointestinal tract, obstruction of this limb presents a resulting in a dramatic body mass index (BMI) reduction during diagnostic challenge. Failure to promptly diagnose and inter- the first postoperative year.In the past 10 years, we have anal- vene can lead to devastating consequences. In order to raise ized 170 morbidly obese patients follow-up underwent this the awareness of practitioners in the community to this potential surgery in Hospital of Valdecilla. problem we, herein, present two cases of biliary limb and one Methods:One hundred seventy consecutive morbidly obese case of alimentary limb obstruction after RYGB and review the patients who underwent a VBG were followed up during 10 relevant literature. years.BMI evolution was monitored.The mean patient age was 45 years (range 18-66 ).There were 143 women and 27 men P19.THE USE OF ENDOSTAPLERS IN THE RECONVER- with a mean body weight of 124 kgs.(range 100-245) who were SION OF A FAILED VERTICAL BANDED GASTROPLASTY mean BMI of 52.8.%. TO BILIOPANCREATIC DIVERSION (SCOPINARO). Results:In the overall evolution of BMI at 10 years 87% of C. F.Escalante, A.Domínguez-Diez, A.Ingelmo, F.Olmedo, M. patients had a BMI over 35 put into the category of low-risk G. Fleitas. Institute of Digestive Diseases. Hospital U. “Marqués weight, a value considered an indicator of the successor failure de Valdecilla”. Santander.Spain. of the intervention.In the post-operative assessment the aver- Background:The vertical banded gastroplasty has been age time in hospital was 11.8 ±5.39 days.At the 10-year follow- widely used for the last years in morbid obesity surgery. Its up visit, vomiting and constipation were reported less frequently. results are controversial because patients gain or do not loss On the other hand, half of the patients expressed a clear ten- the expected weight (2 and 5 years later).These patients use to dency to commit dietary transgressions, and to ingest food at have a pre-gastroplasty Body Mass Index (BMI) >45 or very unscheduled times.The morbidity during the immediate postop- specific personal alimentary costumes. In such cases new erative was in 5 patients:wound infection (2), adult respiratory surgery consists of both restrictive and derivative techniques, distress syndrome (2), and suture dehiscence associated with either a gastric bypass or a biliopancreatic diversion.We pre- peritonitis (1).The morbidity at the 10-year follow-up was in 15 sent a serie of 18 patients who underwent a reconversion of a patients (9.6%), whose were reoperated:2 stenosis neo piloro previous gastroplasty, performing a biliopancreatic diversion and reconverted to Fobi, 5 weight gain with 2 reconverted to using endostaplers in all the steps of surgery .We obtained Fobi (one of them is 3-ro), 2 sutures dehiscence from staple just excellent results and no mortality, with shorten in hospitalisation reconverted to another re-VBG and other to Scopinaro, 6 inci- and a significant reduction in morbidity. sion hernia (3 associated with 3 cholecistectomy).Fourteen Methods:Surgery of morbid obesity was firstly introduced in patients underwent associated cholecystectomy (2 with the our Hospital in 1989, since then 175 vertical banded gastro- VBG, 5 with the reoperations and 7 during the follow-up period). plasties have been performed.After 2 years, and more impor- The mortality was in 3 patients due to respiratory failure and tantly after 5, up to 45% of patients start to gain weight.These subphrenic abscesses with sepsis and multi-organic failure. patients use to have a pre-gastroplasty BMI >45 or specific ali- Conclusions :We conclude that vertical banded gastroplasty mentary habits. We made reconversions in 18 patients, who at long term can reduce overweight of obese patients but not underwent vertical banded gastroplasty and gained weight.In cure obesity .Pitfalls and morbidity were minor than 10%. all the cases a biliopancreatic diversion was performed, using Reoperations were performed avoid more morbidity and gain endostaplers in all the steps of surgery, sections and anasto- weight. mosis, taking the previous band out and cutting off the staplers line of the stomach with the endostapler.At 4th or 5th day after P18.SMALL BOWEL OBSTRUCTION FOLLOWING LONG surgical operation a radiological barium control was made. LIMB ROUX EN Y GASTRIC BYPASS FOR MORBID OBE- Results:Results are globally good.At one year follow-up after SITY.PRESENTATION OF 3 CASES. surgery, a reduction of 75% of overweight has been observed, T.Daskalakis, J. Nicastro, H. Mcmullen, G. Coppa, J. N. with a good quality of life assessment with several tests. Cunningham, J.Macura. Maimonides Medical Center, Brooklyn, Surgical time has been reduced to 135 minutes. There have NY and Staten Island University Hospital, Staten Island, NY , been no deaths and morbidity is very low.No anastomotic fis- USA tula has developed, no biliar leakage or metabolic-respiratory Surgery for morbid obesity has become one of the most suc- complications have been observed. The unique complication cessful modalities for dealing with a clear public health issue. has been an infection of surgical wound. The Roux en Y Gastric Bypass (RYGB) has become the “gold Conclusions :According to our experience, biliopancreatic standard”procedure in the United States over the past decade. diversion performed with endostaplers is a good option for failed Approximately 36,000 bariatric procedures are performed in the gastroplasties.It diminishes surgical time and postoperative U.S.each year of which 25,000 are RYGB’s. complications.The results on weight loss and quality of life are We report three cases with bowel obstruction after RYGB. In excellent. all three patients the obstruction was near the enteroenteros- tomy site.In the first patient the obstruction was of the alimen- P20.QUALITY OF LIFE AFTER ROUX-EN-Y GASTRIC tary limb, while the other 2 patients had a complete obstruction BYPASS (RYGBP). of the biliary limb.The patient with obstruction of the alimentary Joel Faintuch, Priscilla L.R.C. Machado, Monica A. Rudner, limb developed gangrenous ischemia of the proximal bowel. Arthur B.Garrido Jr , Luiz V.Berti, Marlene M.Silva, J.J.Gama- One of the patients with biliary limb obstruction developed gan- Rodrigues. Obesity Surgery Group, Hospital das Clinicas, Sao grenous perforation of the stomach and the other underwent Paulo, SP, Brazil lysis of adhesions and decompression prior to ischemic change Background:Weight loss is the main registered variable after

Obesity Surgery,11, 2001 429 Crete Abstracts bariatric procedures, but patients’feelings and reactions in the ricemia 5.0 0 10.0 90.0 postoperative period are also valuable.In a prospective study of CRI53.5 0 15.9 84.1 Hypo- thyroidism 8.5 10.0 090.0 200 consecutive RYGBP subjects, BAROS quality of life test Bronchitis 6.0 41.7 41.7 16.7 GERD4.5 0 11.1 88.8 was applied, aiming to define the psycho-social impact of the Arrhythmia22.5 4.4 22.2 73.3Depression13.0 46.2 7.7 46.2 operation. Angina 4.0 12.5 37.5 50.0 Anxiety 8.5 64.7 11.8 23.5 Methods:Response to the questionnaire was divided into Conclusions :1) Disappointing outcomes involved varices, Moorehead-Ardelt (MA) quality of life score (-3 to +3) and Oria- hypothyroidism, and anxiety; 2) Very encouraging responses Moorehead (OM) protocol, which included the former plus nutri- were seen in face of sleep apnea, chronic respiratory insuffi- tional, medical and surgical results (1 or less up to 9 points).Age ciency, GERD, hyperlipidemia and hyperuricemia;3) Additional of the population was 39.6 ±6.0 years (82.0% females), 85.5% comorbidities exhibited moderate improvement. of the group suffered from comorbidities, and follow-up period Acknowledgement:The support of F APESP Grants 00/ 1609-9 was 17.6 ± 8.0 months. Preoperative Body Mass Index (BMI) and 00/1610-7 is appreciated. was 50.0 ±8.9 kg/m2, and 64.6 ±9.0% of excess body weight was eliminated, to a BMI of 31.7 ±4.6 kg/m2. P22.NEW POSITIONING OF THE PORT SYSTEM. Results:MA outcome was 1.6 ± 1.0, with 5.0% failures Francesco Furbetta, G.Gambinotti. Ospedale di Pescia, Pescia, (greatly diminished, diminished or unchanged quality), 57.0% PT, Italy had improved and 38.0% had greatly improved after surgical Background.The previous vertical positioning of the port treatment.OM protocol revealed 5.2 ± 1.9 points, with 9.5% resulted, after 4-5 years, in breakage of the port tubing system failed or fair results, 37.5% good, 35.0% very good, and 18.0% in 10-15% of patients. Half of these had to undergo a laparo- excellent outcomes. Preliminary matching of the two sets of scopic procedure under general anesthesia in order to take the findings was already imperfect, and when MA numbers were tubing out of the abdomen, where it had fallen after breakage eliminated from the complete OM questionnaire, statistical sim- (this is considered a major complication).The other half had to ilarity was weak (p< 0.05). have leakage of the tubing or twisting of the port fixed under Conclusions :1) General scores for quality of life and general local anesthesia.The positioning of the port system trans- outcome of the operation (AM and OM tests) corresponded to versely, subcutaneously and parallel to the anterior abdominal expectations, with a large majority of good and excellent wall protects the function and the integrity of the two compo- responses;2) Separation of clinical course from psycho-social nents of the system: 1) the port itself and 2) the connection impact indicated that these results are relatively independent;3) between the port and the tubing. Further studies are necessary to identify prognostic factors for Methods:Description of the procedure:1) The tubing is taken patient insatisfaction with surgical outcome despite appropriate out from the left anterior axillary trocar hole and, by a ligature, shedding of excess body weight. the tubing loop comes out of the left midclavicular trocar hole.2) After all the trocars have been taken out, the midclavicular tro- P21.RESPONSE OF COMORBIDITIES TO ROUX-EN-Y GAS- car hole has to be enlarged (5cm) towards the midline in order TRIC BYPASS (RYGBP). to contain the port.3) In this hole 4 nonabsorbable stitches are Joel Faintuch, Monica A. Rudner, Priscilla L.R.C. Machado, applied above the fascia and through the portholes in such a Arthur B.Garrido Jr, Marcelo R.Oliveira, J.J.Gama-Rodrigues. way that the port is close to the midline.4) From the extreme lat- Obesity Surgery Group, Hospital das Clínicas, Sao Paulo, SP, eral point of the same hole a curved instrument is introduced Brazil and passed above the fascia, coming out in the hole where the Background:Comorbidities contribute not only to surgical tubing comes out.The end of the tubing is grasped and pulled indication, but also to a large measure of success or failure of subcutaneously as far as the site of the port.1)The tubing is bariatric operations.Nevertheless, rates of response of individ- connected to the port. 2) By pulling the loop of the tubing, it ual troubles are disputed.In a prospective study of 200 consec- comes into the straight subcutaneous position.3)The sutures of utive RYGBP subjects, 16 diseases or manifestations were fol- the port are closed.4)The rest of the loop of the tubing is repo- lowed, aiming to document their relief or not after surgical treat- sitioned in the abdomen. ment. Results and Conclusion :This positioning permits: easy Methods:Variables included diabetes, hypertension, snoring, access (anterior m.fascia), durability (4 stitches to the anterior sleep apnea, chronic respiratory insufficiency (CRI), chronic m.fascia prevent dislocation, well accepted and in a hidden bronchitis, cardiac arrhithmia, angina pectoris, varices, axial position (upper abd. fascia), keeps open the most frequently arthritis, hyperlipidemia, hyperuricemia, hypothyroidism, gas- used surgical access points (along the linea alba), does not troesophageal reflux (GERD), depression, and anxiety.These interfere with body movements or bending The connection por- aberrations were assessed preoperatively and after 17.6 ±8.0 tion of the access port system is straight and prevents any months, and late results were described as inadequate, partial breakage, which in the past was caused by kinking of the tubing response and total remission.Age of the population was 39.6 ± very close to the connector. Our technique avoids the above- 6.0 years (82.0% females), preoperative BMI was 50.0 ± 8.9 mentioned complications and permits easy access to the port and last BMI was 31.7 ±4.6 kg/m 2. tubing system in the subcutaneous under local anesthesia. Results:Findings are displayed in the Table as percentage of P23.MINOR LA TE COMPLICA TIONS OF ROUX-EN-Y GAS- the total population (Pre-op), and as percentage of affected TRIC BYPASS (RYGBP). patients (Post-op responses). Variable Pre-opInadequate PartialTotal Variable Pre-opInadequatePartial Total R Sergio Z.Gil, Monica A.Rudner, Priscilla L.R.C.Machado, Joel Diabetes 12.0 12.5 29.2 54.2 Varices8.0 100.0 00 Faintuch, Arthur B. Garrido Jr, J.J. Gama-Rodrigues. Obesity Hyper- Surgery Group, Hospital das Clinicas, Sao Paulo, SP, Brazil tension 43.0 8.1 27.9 62.9 Arthritis 39.5 10.1 31.6 58.2 Background:Technical and medical advances in periopera- Snoring 51.5 2.9 19.4 77.7Hyperlipidemia 20.010.0 7.5 82.5 Sleep tive management of bariatric candidates have greatly reduced apnea 32.5 0 7.7 92.3 Hyperu morbidity and mortality.However, these severely obese patients

430 Obesity Surgery,11, 2001 Crete Abstracts are still prone to a variety of medium and long-term disorders.In complications8 ( 22,2 %) 1 (6,25 %) 0 ( 0 %) a prospective study of 200 consecutive subjects, minor com- Band plaints were systematically registered, aiming to document their infection 2 0 0 frequency by 2 years after operation. Slippage 6 0 0 Pouch Methods:Patients were assessed after 17.6 ±8.0 months by dilatation 1 0 0 means of a detailed interview, and findings were classified Non according to four categories:abdominal wall problems (hernia, compliance 1 0 0 eventration), gastrointestinal (GI) abnormalities (vomiting, diar- Band rhea, flatulence, dumping), nutritional and metabolic aberrations rupture 1 0 0 (anemia, hair loss, cramps, hypokalemia, weakness), and mis- Abdominal cellaneous complaints. Exclusions encompassed manifesta- Adhaesions 1 0 0 tions already present before operation, bariatric failure (exces- Maior sive or insufficient weight loss), psycho-social disturbances complications12 ( 33,3 % ) 0 (0 %) 0 (0 %) (anxiety, depression, substance addiction), as well as all acute Conclusion:Complications rate in the first group is rather disorders requiring immediate investigation or therapeutic inter- high.Following the changes in operative technique the results vention.Age of the population was 39.6 ± 6.0 years (82.0% became better.The results in the second and third group shows, females), preoperative BMI was 50.0 ± 8.9 and last BMI was that with gaining and sharing the experience the results could 31.7 ±4.6 kg/m 2. be improved. Results:Hernias and eventrations were uncommon (respectively 5.5% and 3.0%), and the same was true for GI abnormal- P25.PROPHYLAXIS OF THROMBOEMBOLISM IN BARI- ities except for vomiting, that occurred in 33.5% (dumping in ATRIC SURGERY. 5.5%, diarrhea in 3.0% and flatulence in this same proportion). A.S.Lavryk, V.F.Sayenko, O. P.Stetsenko, O. S.Tywonchuk, V. Among nutritional and metabolic deficits, hair loss was noticed J.Smorzhevsky, O. F.Bubalo. Institute of Surgery & by 28.0%, anemia affected 8.0%, 5.5% had occasional cramps Transplantology Kyiv, Ukraine or hypokalemia, and 3.0% complained of weakness.Finally , Background:Morbidly obese patients have high risk for 3.0% each pointed out memory loss and dizziness after RYGBP. development venous thromboembolism.Cause with an extreme Conclusions :1) Hair loss is a rarely documented complica- weight they are not enough mobile therefore their cardiac, ves- tion but was mentioned by nearly one third of the population, sels and respiratory systems are more vulnerable.Prophylaxis despite routine supplementation of vitamins and minerals; 2) of thromboembolism is very important in bariatric operations. Occasional vomiting was also observed by one third of the Methods:Since 1998 we have performed 45 nonadjustable group;3) Abdominal wall defects were infrequent, and the same open gastric banding, 8 adjustable open gastric banding, 2 BPD was true for the remaining investigated abnormalities. and 3 RYGB. There are 56 females and 2 males.Weight 95 – 187 kg with mean BMI -47, 2 ( 36 –67 ) kg/ m 2.Our prophylaxis P24.LOWERING THE COMPLICATIONS RATE IN LAP-BAND of venous thromboembolism was combined:intermittent pneu- PROCEDURES BY COOPERATION AND EXPERIENCE. matic compression,leg elevation,elastic stockings,early ambula- Pavol Holé czy 1, Vladimí r Medveck 2, Albeta Holé czyová 1, tion.We used low moleculary weight heparins(LMVH): at 30 Linhartová Nadeda 1. 1Surgical Department, Railway Hospital, patients –fraxiparine (nadroparinum) – 0,6ml (5700 UI AXa), 18 Bratislava, Slovakia 2Surgical Department, VS Hospital, Koice, –clexane(lovenox)-enoxaparine – 0,4ml ( 4000 UI AXa) and 10 Slovakia –fragmin (dalteparine) 5000 IE.The standard dose of LMVH has Background:Our surgical department are the only two in used as subcutaneous injection 2 hours before operation, than Slovakia performing obesity surgery.The aim of our paper is to once daily from 1 postoperative day before an enough activation analyse complications in the three groups of patients following of patient (mean – 5 - 7 days ). Also all of our patients have laparoscopic adjustable gastric banding done for morbide obe- becomen a pentoxiphyllin i.v.during the 3 postoperative days as sity.In all the patients the silicone adjustable gastric banding an antiaggreg ate therapy. We performed also 25 (LAP-BAND , Bioenterics, USA) was used. Trendelenburg‘s procedures and 17 veinectomies as a prelimi- Methods:Retrospective analysis of the three groups . The nary operations by patients with a varicose veins.Bariatric pro- operations in the first group were performed from December cedures carried out by their after 7 days. 1997 to December 1999 in Bratislava (36 patients), in the sec- Results:We not observe venous and pulmonary thromboem- ond group from January 2000 to April 2001 in Koice (16 bolism in any patients.We have not local and systemic haemor- patients) with close cooperation between staff in these two insti- rage complications during LMVH using. tutions, and the third group in the same time in Bratislava (16 Conclusion:The profilaxis of thromboembolism play an one of patients). the main role in surgery especially by bariatric procedures.We Results:Are listed in the table are suggested also that a preliminary operation on veins of low n=36 n=16 n=16 extremity must done always at patient with varicose. M : W 11 : 25 2 : 14 3 : 13 Age 21 – 55y 19 – 52y 22.50 P26.BODY COMPOSITION STUDIES IN OBESE CHILDREN. ( av.34,1) 1( av.34 )(av.38,8 ) Renata B.A.Leme, Marilisa S.Froes, Eduardo Meirelles, Ari L. BMI Cardoso, Andrea Nascimento, Cristiane A.R.Charles, Arthur B. 2 kg/m 38 – 59 38 – 52 39 – 66 Garrido Jr, Joel Faintuch. Obesity Group, Children`s Institute ( av.45,6 ) (av. 43,5 ) (av.46,7) and Hospital das Clinicas, Sao Paulo, SP, Brazil Port infection 5 0 0 Background:Severe obesity is affecting increasing numbers Port of young subjects, thus raising the question of body composition migration 3 1 0 monitoring in such circumstances.In a prospective study of out- Minor patient children, bioimpedance analysis (BIA) was compared

Obesity Surgery,11, 2001 431 Crete Abstracts with body densitometry (DEXA), aiming to define the best decreasing weight and so intra-abdominal pressure.Depending method for assessment of major body compartments in this age on the different techniques performed GERD can also be group. improved. Methods:The children (n= 41, 9.5 ±1.3 years, 23 females) Methods:A total of 138 bariatric procedures were performed had a body mass index of 29.0 ±6.1 kg/m 2.BIA was done by between 1996 and 2000. T wenty one cases were selected on the classic tetrapolar technique (single frequency) whereas the basis of having been performed esophagic pHmetry and DEXA was obtained in a LUNAR densitometer.Both findings manometry preoperatively, 3 months postop., and 1 year after were compared with standard anthropometric measurements surgery.Techniques performed were: Vertical banded gastro- and growth charts. plasty (VBG) - 7 patients, and Roux-en-Y Gastric Bypass Results:BIA indicated body fat of 33.0 ± 12.0% of body (RYGB)- 14 patients. Data regarding bariatric procedure, weight (BW), body water of 48.0 ± 6.0% BW, and body cell Excess Weight loss (%), clinical symptoms of GERD , and mass of 29.0 ±5.0% BW.These findings were consistent with results of esophagic manometry and pH-metry were taken into some accumulation of body fat, but not as much as clinically account.Manometric parameters evaluated were the inferior identified.At the same time body water and body cell mass were esophagic sphincter pressure and its total length, wave ampli- relatively diminished, but less than expected for the degree of tude and % of tertiary activity.pH-metry evaluated parameters obesity.DEXA pointed out 47.3 ± 6.9% of body fat, which were the percentage of pH<4 in 24-h time and DeMeester test. closely matched anthropometric evaluations. Results:Mean excess weight loss at 3 months post-op was Conclusion:BIA had serious limitations in the investigation of 46.6 ± 12.3 % for VBG patients and 44.3 ± 7.7 % for RYBG obese children, whereas DEXA fully corresponded to clinical patients, and at 1 Year post-op was 60.0 ±9.1 % for VBG and assessment.Although it is more expensive, DEXA should be the 77.3 ± 7.2 % for RYGB, respectively.Results about method of choice for body composition determinations in that Gastroesophageal reflux disease are shown in table below population. % patients with GERD VBG RYGB Preop3-m 1-y Preop3-m 1-y postop postop Preoppostop postop P27.DOES REDUCTION IN GASTRIC ACID SECRETION Assessed INCREASE THE DAILY ENERGY EXPENDITURE? by symptoms 57.1 %28.5 %14.2 %64.2 %14.2 %0 J.Melissas, E.Kampitakis , G.Schoretsan itis, E.Kouroumalis Assessed by techniques 57.1 %14.2 %14.2 %57.1 %7.1 %7.1 % Bariatric Unit, Dept.Surgical Oncology, University Hospital, Conclusions :Esophagic pH-metry and manometry are valu- Heraklion Crete Greece. able methods to assess the presence of GERD and the Background:Aim of this study was to investigate if reduction changes in GERD after bariatric surgery.There is a high preva- by pharmaceutical means of gastric Hcl acid secretion is able to lence of GERD in morbid obese patients candidates for surgery. lead to significant increase of diet induced thermogenesis Bariatric procedures can improve GERD in morbid obese (D.I.T), therefore in higher total daily energy expenditure (T.E.E). patients.In our experience, the Roux-en-Y Gastric By-Pass is Methods:20 volunteers were included in this study, in each of better than the Vertical Banded Gastroplasty in reducing GERD whom resting energy expenditure was measured, by indirect when it preoperatively exists. thermidometry, following 12 hours fasting. A standard known composition meal of 1000 Kcal was then given, followed by P29.ANASTOMOTIC COMPLICATIONS AFTER ROUX-EN-Y measurement of the energy expenditure (D.I.T) for 0-8 hours. GASTRIC BY-PASS FOR MORBID OBESITY: A SAFE PRO- All volunteers were then placed to 150mg Laprasol Per Os daily CEDURE.. for 2 months.At the end of this period we repeated the mea- Joaquin Ortega, Carlos Sala, Jose Martinez-Valls, Salvador surement of R.E.E and D.I.T following the same standard meal. Lledo.Morbid Obesity & Endocrine Surgery Unit, Clinic Hospital Omeprassol IV 40mg was given I.V.prior to the measurements and University of Valencia, Valencia, Spain in order to further minimize gastric acid secretion. Background:Roux-en-Y Gastric Bypass (RYGB) is consid- Results:Statistical analysis of data shows that there are not ered one of the preferable techniques in bariatric surgery, as it significant changes in both R.E.E and D.I.T following reduction is the gold standard with which other operations should be com- of gastric acid secretion by H2 reseptors antagonists. pared.Although it is considered a safe technique with low mor- Conclusions :Pharmaceutical reduction in gastric acid secre- bidity and mortality rates, anastomotic complications may tion does not significantly increase the T .E.E.Presumably , appear in the early (leak, hemorrhage) or in the late postopera- reduction in gastric acid secretion, as seen following gastric tive period (ulcer, stenosis).T o evaluate the incidence and treat- bypass and gastrectomy, is NOT the mechanism of weight loss ment of choice of anastomotic complications after RYGB for observed in these patients. Therefore other mechanisms morbid obesity in our series. responsible for this phenomenon has to be hypothesised and Methods:A total of 96 RYGB have been performed from 1997 investigated. to March 2001.We performed a stapled-transected RYGB with retro-colic and retro-gastric stapled circular (15-mm internal P28.GASTRO-ESOPHAGEAL REFLUX DISEASE IN OBESE diameter) side-to-side gastro-jejunal anastomosis and stapled PATIENTS.MODIFICATIONS INDUCED BY BARIATRIC closure of the jejunal stump. The Roux-en-Y was end-to-side SURGERY. handsewn between 150 and 200 cm.depending on the BMI (in Joaquin Ortega, Carlos Sala, Maria Escudero, Francisco Mora, 7 cases Distal RYGB at 100 from the ileo-cecal valve). The Adolfo Benages, Vicente Sanchiz, Jose Martinez -Valls, mesenterium opening of the jejunum was always handsewn Salvador Lledo. Morbid Obesity & Endocrine Surgery Unit, closed to avoid internal hernias.Oversuture of the staple lines Clinic Hospital and University of Valencia, Valencia, Spain were only performed when active bleeding or a closure defect Background:Obese patients are known to have increased were present.Gastrograffin Rx check of the anastomosis was intra-abdominal pressure causing frequent gastro-esophageal not routinely performed. reflux disease (GERD). Bariatric surgery can reduce GERD by Results.Anastomotic complications are showed on table

432 Obesity Surgery,11, 2001 Crete Abstracts below.Early postoperative complications Late postoperative Systems, Portland OR‡, USA complications Anastomotic bleeding 2 2% Anastomotic stenosis Background:Laparoscopic bariatric surgery requires 4 4.1% Leak 1 1% Anastomotic ulcer 1 1%.Subphrenic abscess advanced laparoscopic skills.The growing demand for laparo- 1 1%.One of the two patients whose anastomosis bled required scopic gastric bypass and other minimally invasive bariatric pro- surgical revision after endoscopic failure and persistent shock, cedures requires training of new physicians and new skill acqui- and in the operation no active hemorrhage was found.The leak sition for established bariatric surgeons.The methods available was suspected due to patient´ s early postoperative agitation for providing this training include minimally invasive surgery fel- and tachicardia.After gastrograffin Rx confirmation the patient lowships with a focus on obesity, weekend courses, proctor was re-operated and the defect at the angle of the reservoir sta- assistance and mini-fellowships.The purpose of our submission ple line was sutured. The subphrenic abscess was percuta- is to report our first 10 months of experience following fellowship neously drained, and no enteric comunication could be demon- in minimally invasive surgery. strated.The 4 anastomotic stenosis were resolved with one- Methods:A retrospective review of all laparoscopic bariatric session endoscopic balloon dilatation. The patient with the procedures performed by three surgeons during their first year anastomotic ulcer responded to omeprazol.All patients did well of practice.All surgeons successfully completed a one-year clin- after appropriate treatment. ical laparoscopic fellowship that concentrated on bariatric Conclusions :Roux-en-Y Gastric Bypass can be considered a surgery.Outcomes analyzed were operative time, conversion safe operation with a low morbidity rate.In our series, anasto- rate, blood loss, morbidity and mortality. motic complications were less than a 10%, according to litera- Results:A total of 85 laparoscopic bariatric operations were ture reports.In most cases, anastomotic complications can be performed from July 2000 to May 2001 at 3 separate institu- resolved with non-operative treatment. tions, utilizing the same surgical technique. The cases performed included: 9 laparoscopic adjustable silicone gastric P30.PSYCHSOCIAL OUTCOME OF LASGB-OPERA TIONS bandings (LASGB), 66 laparosco pic Roux-en Y gastric IN ADOLESCENTS. bypasses (LRYGB) and 10 laparoscopic biliopancreatic diver- T.Pachinger, F .Schmoeller*. Private practice for clinical psy- sion with duodenal switch (LBPDDS). There were 74 females chology, Elisabethinen hospital Linz, Department of Surgery*, and 11 males, with a median age of 42 (range 18-66) and aver- Austria age BMI = 49 kg/m2 (range 37-67). The mean operative time Background:Surgical treatment is widely not accepted as was 202 minutes, (122 minutes- LASGB, 190 min- LRYGB, 299 therapy for morbidly obese juvenile patients.Nevertheless non- min-LBPDDS).Average estimated blood loss was 110 ml.There surgical treatment frequently fails to be successful over a longer were 3 conversions (1 LRYGB, 2 LBPDDS) for a rate of 3%; period.Considering especially the severe psychosocial and indications included large liver, intra-operative leak and exten- physiological consequences of morbid obesity in these patients sive adhesions.Length of stay was 1 day for LASGB and 3 days surgery seems to be the “last hope“ in special cases . for both LRYGB and LBPDDS.There were no mortalities.Major Methods:In three of 237 patients operated on with LASGB- complication rate was 3% and included 1 re-operation for bleed- procedures between XII 1996 and III 2001 we decided to per- ing, 1 re-operation for small bowel obstruction and 1 distal anas- form the operation in spite of their age (15, 16, 17 years ) due tomotic leak which was successfully treated non-operatively. to their individual situations. Indications for surgery in these Wound infection rate was 8% and stomal stenosis rate was 8%. cases were: familiar history of severe obesity , progressive Conclusion:Laparoscopic bariatric operations are complex weight increase (BMI of 51, 54 and 61), numerous failed non- procedures that require advanced minimally invasive skills.Our surgical therapies and weight associated comorbidities. All results demonstrate that a dedicated training program provides patients had multiple psychosocial problems such as discrimi- a platform for acceptable early results.The major complication nation in social situations, disadvantages concerning school rate of 3%, even with one year of training, highlights the neces- and job, social isolation, restriction in physical activity and con- sity of intensive hands on instruction and questions the ade- sequently loss of self acceptance.In addition to medical obser- quacy of weekend courses as a sole source of education for vation we performed quality of life questionaires and psycholog- most physicians. ical interviews in all three adolescents 12-24 mths.postopera- tivly. P32.USE OF BAROS SCORE SYSTEM IN PATIENTS OPER- Results:All patients reported enormous improvement in life ATED ON FOR MORBID OBESITY: RESULTS OF OUR quality and impact of their psychosocial situation.So far no psy- SERIES. chological or medical problems occured in these patients. At Carlos Sala, Joaquin Ortega, Fernando Ló pez, Stephanie present each of them is satisfied with the outcome of the oper- García, Jose Martinez-Valls, Salvador Lledo. Morbid Obesity & ation and would recommend it to other juvenile obese patients Endocrine Surgery Unit, Clinic Hospital and University of as well. Valencia, Valencia, Spain Conclusion:In special cases LASGB-operations seem to be Background:The analysis of the results of bariatric surgery is a therapeutic option for morbidly obese juveniles as well as for not only based on weight loss but also includes other aspects of adults.In our patients the impact of their psychosocial and phys- the quality of life of these patients such as changes in co-mor- ical situation was excellent. bid conditions.Recently , the B.A.R.O.S.score system has been accepted by the Spanish Society of Obesity Surgery as an offi- P31.IMPACT OF MINIMALLY INVASIVE SURGICAL FEL- cial measurement instrument. T o evaluate the influence of LOWSHIP ON EARLY OUTCOMES IN LAP AROSCOPIC bariatric surgery in our patients´ life using the B.A.R.O.S.score BARIATRIC SURGERY. system. Christine J.Ren MD*, Marina Kurian MD†, Mitchell Roslin MD† Methods:A total of 93 patients operated on for bariatric and Emma Patterson MD‡. NYU School of Medicine, New York, surgery have been followed for more than one year.Operations NY*; Lenox Hill Hospital, New York, NY† ; Legacy Health performed include 42 Vertical Banded Gastroplasty (VBG) and

Obesity Surgery,11, 2001 433 Crete Abstracts

51 Roux-en-Y Gastric By-pass (RYGB) from 1995 to 2000. A Total costs Total costs B.A.R.O.S.questionnaire was sent out to all these patients to be = 5038.3 ±227.6 = 3020.2 ±387.0 * completed and returned. Inhospital stay (days):Inhospital stay (days): Results:90 questionn aires were completed (57 mail 8.1 ± 0.8 3.9 ± 0.5 * ICU Stay (hr.): ICU Stay (hr.): returned, and 33 completed during outpatient visits).The mean 36.0 ± 16.1 14.4 ±9.1 * follow-up was 32.7 months for the VBG group, and 18.4 months Operating time (min.):Operating time (min.): for the RYGB group.T echnique Excellent Very Good Good Fair 165.0 ±26.9 N=10;93.5 ±13.2 * Failure T otal acceptable results VBG 21.4% 23.8% 28.6% Conclusions :By the time the bariatric surgeon gains experi- 14.3% 11.9% 73.8% RYGB 37.3% 41.2% 13.7% 5.8% 2% ence a reduction in costs is achieved.Morbidity decreases with 92.2% the learning curve, though it does not reach statistical signifi- Conclusions :A standard measurement system is necessary cance.RYGB is safer and more cost-effective than VBG. to be able to compare different series in bariatric surgery , in order to evaluate not only the weight reduction but the improv- P34.DUODENO-GASTRIC BILE REFLUX AFTER ROUX-EN- ing in quality of life.In this field, the results of RYGB appear to Y GASTRIC BYPASS. be superior to VBG. Overall, bariatric surgery in our series are Magnus Sundbom, Sven Gustavsson. University Hospital, generally very acceptable.However, weight loss is superior and Uppsala, Sweden easier to keep on RYGB patients, and in our Unit, we nowadays Background:Roux-en-y Gastric bypass (RYGBP) leaves the usually perform RYGB, reserving VBG for only selected cases. excluded stomach not readily available for endoscopic or other examinations.There are reports on the development of chronic P33.THE LEARNING CURVE IN BARIATRIC SURGERY: gastritis with intestinal metaplasia in the excluded stomach after IMPLICATIONS IN MORBIDITY AND COSTS. RYGBP.Duodeno-gastric bile reflux (DGBR) has been postu- Carlos Sala, Joaquin Ortega, Jose Martinez-Valls, Salvador lated to contribute to gastritis. Lledo. Morbid Obesity & Endocrine Surgery Unit, Clinic Hospital Methods:22 patients (20 females, median (range) age 40 and University of Valencia, Valencia, Spain (25-50) years) were studied 50 (25 - 75) months after RYGBP. Background:It is widely thought that the larger the experi- BMI before surgery and at the time of cholescintigraphy was 45 ence of the surgeon , the lesser the morbidity in surgery.This (40 - 50 and 29 (19 - 32), respectively.All patients had a stable saying is probably true in many fields of the surgical practice. body weight.15 patients had had their gallbladder removed.200 Surgery for the morbidly obese patient is a recent new field in MBq 99mTc-labelled mebrofenin was injected intravenously and general surgery , and in many surgical departments has been the fate of the radioactivity was followed in a computer-assisted developed from zero since few years ago.T o evaluate the effect gamma camera.Bile flow was enhanced with iv cholecystokinin of the learning curve in decreasing morbidity and costs in (75 dog units).20 MBq Iv 99mTc-pertechnetate was used for bariatric surgery. localisation of the stomach. Methods:Since our Unit became involved in bariatric surgery Results:Dynamic analysis of stored gamma camera images in 1995 we have performed 138 bariatric procedures, 42 Vertical allowed accurate determination of the fate of the tracer in all Banded Gastroplasties (VBG) and 96 Roux-en-Y Gastric patients.8 patients (36 %) had evidence of DGBR. The main Bypasses (RYGB). To evaluate complications of each proce- portion of the tracer was transported in an anal direction and the dure, patients were divided in two groups, the older and the amount found in the excluded stomach was less than 20%. newer .To evaluate costs, charts of the first and the last 10 con- Repeat examination performed in two patients confirmed the secutive patients of each procedure were carefully reviewed. presence of DGBR. DGBR occurred equally often in patients Data regarding operating time, technique, in-hospital stay, and with or without scintigraphic evidence of a functioning gall blad- costs were taken into account. der. Results:Table I.Complications Conclusion:DGBR occurs in 36% after RYGBP irrespective TechniqueOlder Newer of gallbladder status. The role of DGBR for development of VBG N=21 N=21 chronic gastritis in the excluded stomach after RYGBP has to be Complications=19.0 %Complications:14.2 % investigated further. 1 Band intrusion,1 Pneumonia, 1Stenosis, 1 Reservoir-cutaneous Fistula P35.BARIATRIC ANAL YSIS AND REPORTING OUTCOME 2 Wound infection1 Wound infection SYSTEM FOLLOWING LAPAROSCOPIC ADJUSTABLE RYGB N=48; N=48 GASTRIC BANDING IN FINLAND. Complications=12.5 %Complications=10.4 Mikael Victorzon, MD, PhD;Pekka Tolonen, MD. Department of 1 Exitus, 1 Leak, 2 Post-op bleeding 4 Wound infection1 Ulcer, 1 Wound infection Surgery, Vasa Central Hospital, Vasa, Finland 1 Subphrenic abscess Background:The reporting on outcome following bariatric Table II:Costs(calculated in euros on a non-profit basis) procedures should include changes in co-morbid conditions and TechniqueOlder Newer quality of life in addition to weight loss.The Bariatric Analysis * p<0.05 (Unpaired Student t) and Reporting Outcome System (BAROS) seems to provide the VBG N=10; means to fulfil these requests.We have re-evaluated our previ- Total costs Total costs ously published, initial results of laparoscopic adjustable gastric = 4314.7 ±287.2 = 2853.5 ±183.2 * banding, using the BAROS. Inhospital stay Inhospital stay Methods:Our first 60 consecutive patients were treated (days):7.4 ±0.6 (days):3.8 ±0.6 * laparoscopically between the years 1996 and 1999, using the ICU Stay (hr.): ICU Stay (hr.): 26.4 ± 7.2 20.4 ± 5.7 Swedish adjustable gastric band.After a minimum follow-up of Operating time (min.):Operating time (min.) ³ 17 months (median follow-up 28 months, range 17 - 61 147.7 ±22.5 N=1072.5 ±20.5 months) a postal questionnaire concerning quality of life, med- RYGB N=10; ical condition and excess weight loss (BAROS) was sent to the

434 Obesity Surgery,11, 2001 Crete Abstracts patients.In addition, the patients opinion regarding the opera- anesthesia in morbidly obese patients remains controversial (1). tion was evaluated as well as to which extent the band had Arterial oxygenation may be extremely impaired during and caused the patients any of the commonest side effects. after surgery (2).Generally , TIVA with propofol and sevorane is Results:87% of the patients returned the questionnaire prop- used for anesthesia management.Inhalation anesthetics such erly answered. According to BAROS, the outcome was as sevoflurane have some bronchodilatatory effects. Other regarded as F AILURE in 21% of cases, as FAIR in 29%, as hand, especially one-lung ventilation protocols showed that pO2 GOOD in 38% and as VERY GOOD in 12%. Not one had an level with using propofol were greater than inhalation anesthet- EXCELLENT outcome.23% of the patients were disappointed ics (2). Propofol may provide lower shunt fraction values than with their operation.The incidence of band related side effects sevoflurane (2). was high. The aim of this study was to investigate respiratory function Conclusion:Our results are comparable with other published tests after two different anesthetic techniques and determined series including the learning curve. In our opinion BAROS convenient technique for laparascopic morbid obesity surgery. should be widely adopted. Method:Thirty patients were studied in two randomized groups (n=15 each).Patients were distributed randomly into two P36.REMIFENTANIL ANESTHESIA CAN REDUCE THE CON- groups as; Patients receiving totally intravenous anaesthesia SUMTION PERIOPERA TIVE INTRA VENOUS MORFINE IN (TIVA) which is group T, andthe others receiving sevoflurane as BILIOPANCREATIC SURGERY IN MORBID OBESE. group S.All of the patients were morbidly obese patients and M.A.Villanueva, F .J.Barredo, A. Muñecas, S. G.Santos, A. they went under laparascopic stoma-regulated gastric bandage Dominguez, F.C. Escalante. S Anestesiologí a y Reanimació n operation.Respiratory functional tests (FVC, FEV1, FE1/ FVC, Hosp Univ Marqués de Valdecilla. Santander, Cantabria Spain FEF 25-100, PEF) were performed 1 day before operation (1 Background:Postoperative pain control is one of the most measure) and postoperative 2.day (2 measure).Student’ s t test important goal in the postoperative period following biliopancre- was used for data analysis.P value smaller than 0.05 were con- atic surgery because the surgery can be painless and an inef- sidered statistically significant. fective pain control may lead to serious complications. The Results:Respiratory tests reduced after the operation in both options for pain management including systemic analgesics ( groups(p<0.05).Whereas In the group T;tests were determined NAIDS and opioids) and neuroaxial opioids and local anesthet- significantly lower than group S (p<0.05). ics which can be very dificult to do in the morbid obese patient. Results: Remifentanil is a new opioid with a short duration of action and FVC FEV1 excellent recovery used during anesthesia for especially situa- 1measure2measure 1measure 2measure tions like the mobid obese Group 88.7±23.9 71.66± 21.1*† 88± 22.1 66.8± 19*† Methods:20 consenting morbidily obese patients sheduled Group S93.4±11.5* 90.3± 11.5 92.7± 12.1 88.06± 11* for elective biliopancreatic bypass participated in the study.All FEV1/FVC FEF25-75% patients were anesthetized with the same anesthetic regime, 1measure2measure 1measure 2measure which included propofol, rocuronio, sevoflorane.T o 10 patients Group 93.6±13.9 89.1± 15.9 82.8± 30.4 70.4± 24.2 were administred fentanil and the others remifentanil for intra- Group S101.2±9.1 96+.5± 6;7 82± 24. 77.5± 22.77* operative analgesia.The postoperative analgesia regimen was PEF effective in all patients and consisted in NAIDS + TRAMADOL + 1measure2measure Morfina in PCA. We compare consumption of morfina in both Group 91.6±84.6 84.6± 18.3 groups of patients 24 after surgery Group S89.3±14.6 84.1± 17.3 Results: All patients were a good pain score in visual ana- Conclusion:It is concluded that, postoperative respiratory logue score (VAS) at rest and were able to sit in a chair a 18 tests were better with sevoflurane compared propofol, when it hours after surgery. 24 hours after surgery the patients were was used as an anesthetic maintenance, during laparascopic doing exercices for their breath and cough, they getting asleep morbid obesity surgery. sometimes, rarely they have nausea and vomiting, and the postoperative consumption of morfina in the group of remifentanil 24 P38.CONVERSION OF FAILED VERTICAL BANDED GAS- h after surgey were 20 mg while the needs of morfina in the TROPLASTY (VBG) TO OPEN ADJUSTABLE SILICONE group of fentanil were 32.84 mg. GASTRIC BANDING (ASGB). Conclusion:Morfina is a good amalgesic but their side effects Mustafa T askin*, Kagan Zengin*, Ethem UnalL*, Ziya in the repiratory and gastrointestinal system in morbid obese Salihoglu**. University of Istanbul, Medical Faculty of patients schedule to abdominal surgery must be considered Cerrahpasa, Department of General Surgery*, Anesthesiology Reduction in consumption of morfina 24 hours after surgery can **, Istanbul, Turkey be because the first dosis before the surgery is finish is larger in Background:An increasing number of patients with failed group of remifentanil or because with remifentanil is achieved a VBG procedure present themselves for secondary treatment. better control of stimulus nociceptive during surgery. The reoperations in these failed cases can be tried with ASGB Methods:During the period 1991-1997, at General Surgery P37.COMPARISON OF RESPIRA TORY FUNCTION TESTS Clinic of Cerrahpa?a School of Medicine in Istanbul, 80 morbidly AFTER TWO DIFFERENT ANESTHETIC TECHNIQUES FOL- obese patients were managed surgically with VBG. In 7 of them LOWING LAPARASCOPIC MORBID OBESITY SURGERY. the staple line disruption and weight gaining were detected Ziya Salihoglu*, Kagan Zengin**, Sener Demiroluk, Oktay within 3 year (24-48 months) control period.A conversion pro- Demirkiran*, Yildiz Kose*, Mustafa T askin** University of cedure to ASGB was applied between 1994-1998. Meanwhile Istanbul, Medical Faculty of Cerrahpasa, Department of another 80 morbid obese patients were operated with open Anesthesiology* and General Surgery**, Istanbul, Turkey ASGB technique. Background:To choice of anesthetic technique for general Results:In 7 patients (8.75%) staple line disruption appeared

Obesity Surgery,11, 2001 435 Crete Abstracts on the radiography as leakage of the contrast material. After considered statistically significant. conversion of the failed VBG cases to ASGB procedure, the Results:Table I:Respiratory mechanic values early postoperative characteristics were very satisfactory and 1 measure2 measure3 measure4 measure similar to those of our open ASGB-applied group. EV759.7±67 1718.45± 81.6 743.8± 80.1 763.36± 78.08 Conslusions :VBG is a safe technique although reoperation C54.5±10.6 33.7± 6.66* 34.92± 7.3* 45.2± 13.1* Raw 16.4±2.2 22.29± 2.51* 21.12± 2.41* 17.5± 1.92 and conversion rates are high.Staple line disruption constitutes PIP21.6±3.6 26.7± 3.2* 25.8± 2.75* 21.9± 2.5 the chief cause of insufficient weight loss and frequently indi- *p<0.05 compare 1.measure cates the need for further surgery.Our early results of the revi- Conclusion:The negative effect of PP was balanced from the sional surgery confirm that the reoperations in failed VBG cases positive effect of head up position, at the end of PP providing can be tried with ASGB technique. SP, Raw and PIP of C was turned back to normal.Also C getting better but remains lower than 1 measure. P39.BAND EROSIONS FOLLOWING ADJUSTABLE SILI- CONE GASTRIC BANDING(ASGB) FOR MORBID OBESITY. P41.LEARNING CURVE OF THE SURGICAL TREATMENT IN Mustafa Taskin*, Kagan Zengin*, Ethem Unal*, Ziya Salihoglu**. MORBID OBESITY. University of Istanbul, Medical Faculty of Cerrahpasa, A.Bozbora*, Y.Erbil*, S.Ozarmagan*, U. Barbaros*, N.Ozbey**, Department of General Surgery* and Anesthesiology**, Y. Orhan**. *Department Of General Surgery, Istanbul Medical Istanbul, Turkey. Faculty, Istanbul, T urkey, ** Deparment Of Internal Medicine, Background:Adjustable slicone gastric banding (ASGB) Istanbul Medical Faculty, Istanbul, Turkey technique has been advocated as a minimally invasive proce- Background:With the experience of seven years in morbid dure that is a completely reversible for the surgical treatment of obesity surgery, we tried to evaluate the most probable prob- morbid obesity.One of the possible complications of ASGB is lems of the surgeons who have already started to perform mor- band erosion(BE).The aim of this article is to present our expe- bid obesity surgery.We believe that the surgical team that will rience with BE and discuss its possible causes. work on morbid obesity surgery should be well qualified in the Methods:We performed 165 operations (112 women and 53 fields of gastrointestinal surgery , endocrinology and human men) from december 1994 to june 2000 , 85 of which were by metabolism.Also laparoscopic experience is obligatory to laporoscopy.The average lenght of following period is 3 years achieve the success in laparoscopic morbid obesity surgery. (3-52 months) Methods:In our patient group, AGSB (Adjustable Gastric Results:In the examinations of patients with insufficient Silicone Banding) has been performed in 33 patients. In 5 weight loss and excessive vomiting , by double- contrast radi- patients, VBG ( Vertical Band Gastroplasty) technique has been ography and endoscopy , BE was fond in 3 female patients performed.Mean age of the patients was 31 years(23-44).24 (1.81%).Their bands removed by open approach. patients were female, 14 were male.The mean BMI was 41 (36- Conclusions :Band erosion is one of the possible complica- 48).Laparoscopic procedures were performed in 12 patients.In tions after ASGB. It usually develops at least several months fol- 6 patients, we started operation laparoscopically but continued lowing operation. It should be prevented by placing the band and ended the procedure with open surgical techniques. The correctly and keeping away from infection the only treatment of mean operation time 180 minutes in laparoscopic procedures BE is removal of the band. and 56 minutes in open surgical techniques. Results:The mean preoperative weight of the patients were P40.EFFECT OF POSITION CHANGES AND PNEUMOPERI- 130 kg (94-189).During follow up of the patients in postopera- TONEUM ON RESPIRATORY MECHANICS IN THE LAPARO- tive period, except 3 of them all patients had decreasement in SCOPIC MORBID OBESITY SURGERY. their BMI. Over all, mean hospital stay of the patients were 4 Ziya Salihoglu*, Kagan Zengin**, Sener Demiroluk*, Serpil days.As postoperative complication, we mostly detected wound Cakmakkaya*, Yildiz Kose*, Mustafa T askin** University of infection in 7 % of patients.Respiratory infection rate was 3.4 %. Istanbul, Medical Faculty of Cerrahpasa, Department of In a patient we diagnosed Wernicke’s encephalopathy and gas- Anesthesiology* and General Surgery**, Istanbul, Trukey. tric erosion due to band in another patient. Background:In the laparoscopic operations for morbid obe- Conclusion:Morbid obesity treatment with surgical proce- sity surgery, position changes were performed to exposure and dures should be managed by team composed of general sur- access to surgical site. The aim of our study was to evaluate geon, anesthesiologist, endocrinologist and a phyciatrist. The pneumoperitoneum (PP) and position changes on respiratory surgeons who have enough experience in open surgical proce- mechanics during the operation period. dures of morbid obesity , usually perform laparoscopic proce- Method:ASA I-II groups of 11 patients were included in the dures more easily.The most common problem encountered was study.All of the patients were morbidly obese patients and they that the doctors and the patients generally have insufficient and went under laparascopic stoma-regulated gastric bandage false knowledge about the morbid obesity surgery.Also results operation.V entilation was controlled artificially.Tidal volume and and complications of the old surgical methods used in morbid ventilator frequency was kept constant throughout the opera- obesity surgery have negative effects on ideas of patients about tion.Intraabdominal pressure was hold up to 16 mmHg.V entrak new surgical techniques.The surgeons who will be interested in respiratory mechanic (Model 1150, USA) device was used for morbid surgery should be ready to struggle with the wrongly measure to respiratory mechanics. Expiratory volume (EV), and insufficiently informed patient group and lack of enough resistance of airway (Raw), compliance (C), peak inspiratory financial sources. pressure (PIP) was measured.Measuring was performed in four periods.[Supine position (SP) (1 measure), after PP with SP (2 P42.REOPERATIONS AFTER LAP AROSCOPIC ADJUST- measure), at 30 degree head up position with PP (3 measure), ABLE SILICONE GASTRIC BANDING (LAP-BAND® at 30 degree BC with desufflation (4 measure)].Repeated mea- BIOENTERICS-MCGHAN). sure ANOVA was conducted on data.P smaller than 0.05 were U. Elmore, A.Restuccia, N.Perrotta, D. Polito*, E.Bianchi**, N.

436 Obesity Surgery,11, 2001 Crete Abstracts

Lo Martire**, G.Silecchia, N.Basso. Dipartimento di chirurgia In one case the physical intolerance needed to remove the BIB “Paride Stefanini”- Policlinico “Umberto I” Università “La after three weeks implantation.After more than two weeks 102 Sapienza”Roma” , *ASL Roma G, **ASL Frosinone Presidio of our 320 patients didn’ t feel anything, nausea and vomiting Sora, Italy were observed in 92 patients (28.75 %) and we hospitalized 17 Background:In a recent review the reported reoperation rate patients and treated for dehydration. after LASGB ranged between 3.8 % and10.5%.The aim of the Conclusion:We believe that the BioEnteric’ s Intragastric present study was evaluate the reoperation rate after LASGB Balloon can be considered a safe and valid method for obtain- and the related causes. ing good weight loss, if associated with restricted diet, a multi- Methods:From January ‘96 and April ‘01, 34 patients under- disciplinary approach and a good collaboration and motivation gone LASGB (Lap-Band ® Bioenterics-McGhan), 2 of them of the patient. referred to our center, were reoperated under general anesthesia.Other 8 patients experienced reservoir treated under local P44.SHORT-TERM BODY COMPOSITION FOLOWING anesthesia in ambulatory setting. LAPAROSCOPIC ADJUSTABLE SILICONE GASTRIC BAND- Results:the causes of the reoperations, the procedures and ING. kind of anesthesia performed are following showed:irreversible A Diez-Caballero, J.Gómez-Ambrosi, I.Monreal, J.Salvador, J. pouch dilatation (4 pts) laparoscopic band removal under gen- A.Cienfuegos, G. frühbeck. Depts.Of Surgery ,Endocrinology eral ansthesia; intragastric band migration (14 pts) minimally and Biochemistry ,Clínica Universitaria de Navarra-Metabolic invasive band removal under general anesthesia;psychological Research Labaratory,University of Navarra,Pamplona ,Spain problems (5 pts) laparoscopic band removal under general Surgery is the most effective therapeutical option for weight anesthesia;intraperitoneal band system rupture (2) laparo- reduction in carefully selected patients with morbid obesity, scopic catheter connection under general anesthesia;port com- which is resistant to conventional treatment. Considerable plications (7 pts) removal/ substitution under local anesthe- progress has been made in developing safer and less invasive sia.Mortality was nil; mean operative time was 70 minutes; procedures foe promoting weight loss.The goal of the present- wound infection occurred in 2 cases (intragastric band migra- ing study was to determine weight, body composition as well as tion);mean hospital stay was 4 days. metabolic and hormonal changes in the early period of rapid Conclusions :Reoperation rate in our experience was 9% and weight loss. the main reason was intragastric band migration (8.5%).All the Thirteen male morbidly obese patients (mean age:33.4±3.2 reoperations requiring general anesthesia were performed by years) undergoing laparoscopic adjustable silicone gastric minimally-invasive approach, outlining the reversibilit y of banding (LASGB) were evaluated before and three months after LASGB also in case of intragastric band migration. Bariatric surgery.Changes in body composition were assessed by the whole body air-displacement method (BOD POD; Life Measurement Instrumen ts, Concord, CA).Blood analysis P43.BIOENTERICS INTRAGASTRIC BALLOON; A NON included the measurement of glucose, triglycerides, HDL-chole- AGGRESSIVE SOLUTION FOR THE TREATMENT OF THE strol, LDL-cholestrol, insulin, leptin and cortisol concentrations. OBESITY? Already 3 months after LASGB all measurements performed J.Herve, C.H. Wahlen, B.Bastens, B.Dallemagne, C. Jehaes, showed a statistically significant improvement (P=0.0001 for all J.L.Jourdan, S. Markiewicz, J. Weerts. Les Cliniques Saint except for cortisol concentrations P=0.0020-Wilcoxon test). Joseph, Liege, Belgium Mean weight loss was 18.5± 8.3 kg with 10.6± 3.7 kg corre- Background:The concept of using gastric space-occupying sponding to fat reduction. volume devices for the control of obesity was first described in Therefore, approximately 57.3% of the total weight loss 1982. observed was attributable to the decrease of the fat compart- Methods:We propose here a study including 320 BIB placed ment. consecutively to analyse its efficacy in the treatment of obesity, Time Weight (kg) BMI (kg/m2) Fat (%) Fat (kg) Fat free mass (%) its complications and side effects. Before133.9± 6.5 46.0± 2.5 42.7± 1.8 55.5± 3.7 57.3± 1.8 Results:Of the 320 patients, 54 were males and 266 were After 3 mo113.7±4.9 38.5± 1.9 38.4± 2.4 44.3± 4.4 61.0± 2.3 females ( Sex Ratio H/ F:1/4.9);the mean age was 42 years (range 16-71);the mean BMI was 35 (range 28-51) . Time Glucose T riglyceridesHDL LDL Our inclusion criteria were:morbid obesity ( BMI > 40 ) in 46 (mg/dl) (mg/ dl)chol(mg/ dl)chol(mg/ dl) patients, grade II obesity ( BMI 35-40) in 114 patients and grade Before115.6± 8.0 145.2± 21.6 41.5± 1.9 146.8± 9.4 I ( BMI < 35 ) obesity in 160 patients.The mean balloon filling After 3 mo94.4± 4.6 105.1± 25.5 46.1± 3.7 134.4± 12.1 was 529 ml ( 400-700) of sterile saline in which 2 ml of methyl- Time Insulin (UI/l) Leptin (?g/l)Cortisol (?g/dl) ene blue has been added.The mean implantation of the balloon Before 49.0± 9.1 37.7±6.1 23.0±3.3 in the gastric cavity was 35.42 weeks. Mean weight loss was After 3 mo23.9± 5.5 26.7±4.3 6.4±1.1 14.7 kg ( range –45 to +18).Mean male weight loss was 16.4 kg These findings show the importance of performing body com- ( 0-45), and female was 14.32 kg ( -44 to +18).Mean BMI reduc- position measurements during rapid weight loss after Bariatric tion was 4.85 ( -18 to +7). Concerning complications, we surgery to monitor the changes taking place in the fat free mass observed;no death, peptic ulcer;3.75 % ( 12 cases) , esophagi- in order to encourage patients to maintain or even increase the tis;4.69 % ( 15 cases), intestinal occlusions 0.94 % ( 3 cases, lean mass. all treated by laparoscopic surgery) , 2 cases of infection which induced a “mega-balloon”with a hydro-aeric level and one case P45.LAPAROSCOPIC GASTRIC BYPASS FOR MORBID of gastric haemorrhage.During the first week after implantation, OBESITY: FIRST EXPERIENCE WITH 15 CASES. about one third of our patients ( 100/320) didn’t feel anything. M. Weber1;M.K.Mü ller 1, F. Horber2, L.Krähenbü hl 1; R. S. Nausea and vomiting were present in 141/ 320 cases (44%), Hauser3. 1University Hospital Zürich; Clinic for Visceral Surgery, epigastric cramps;84/ 320 (26.2%) and reflux ;66/320 (20.6%). Zürich, Switzerland, 2Klinik Hirslanden, Zürich, Switzerland,

Obesity Surgery,11, 2001 437 Crete Abstracts

3Consultant for Nutrition, Zürich, Switzerland sidered significant. Background:There is increasing evidence that the laparo- Results:Two of the ten patients in the LASGB group were scopic gastric banding is not ideal for all patients with morbid found to have both quantitative esophageal dilatation and visual obesity such as for patients with severe eating disorders, with esophageal fullness; two additiona l patients had visual esophageal dismotility or with a body mass index (BMI) >50 esophageal fullness. All four of these patients were noted to kg/m2.A combined malabsorptive-restrictive procedure like the have a maximally restricted stoma. There was no significant laparoscopic gastric bypass might be an attractive alternative change in esophageal diameter postoperatively in RNYGB and for those patients.The aim of our study is to analyze our first VBG group.One patient reported to have mild esophageal full- experience with this procedure and to report the feasibility of a ness following RNYGB was also found to have a maximally laparoscopic conversion from the gastric banding to the gastric restricted stoma. In the VBG group, one of nine patients was bypass. found to have mild esophageal dilatation and fullness postoper- Methods:Since June 2000, 15 patients underwent a laparo- atively with a normal stoma size. scopic gastric bypass at our clinic. All data were collected Conclusion:Esophageal dilatation and fullness in LASGB prospectively.Indications were a BMI >50 kg/ m 2 (4 patients), patients in this study consistently correlated with maximal Eating-Disorder (6 patients), failure of a previous gastric band- stomal restriction.This represents a marker for stomal restric- ing (3 patients), or an insufficient lower esophageal sphincter (2 tion which is too extreme on a chronic basis.With mild or mod- patients). erate degrees of LapBand restriction, there is no evidence of Results:14 operations were conducted laparoscopically, one esophageal dilatation or fullness. had to be converted to open surgery (6.6%).The average time of operation was 298 min (150-480).Early complications con- P47.LAPAROSCOPIC GASTRIC BANDING: THE LONG sisted of three subcutaneous wound infections and one gastric ISLAND EXPERIENCE. emptying disorder, all of which were treated conservatively . Dorothy R.Ferraro, MS, CS, ANP, Richard B.Rubenstein, MD. Average hospital stay was 12.6 days (7-24). Early follow-up Private Practice:Caremax Wellness and Weight Management showed a BMI reduction from 45.8 to 36.4 kg/m 2 during the first Center, E.Patchogue, N.Y., USA 2 months.A decrease of the BMI from 40 to 28 kg/m2 over 6 Background:Laparoscopic adjustable silicone gastric band- months was observed in the first 2 patients. ing (LASGB) has recently been introduced as a minimally inva- Conclusion:The laparoscopic gastric bypass is in our experi- sive approach to the treatment of medically severe obesity. ence a method with a low morbidity .This procedure offers a Clinical trials are currently being conducted in the United States superb therapeutic option in patients whit contra-indications for on LASGB with the LapBand.Thirty-one procedures were per- pure restrictive methods, and moreover, it might be the only effi- formed between March and December of 1999 on Long Island. cient choice for the increasing number of patients with failed Methods: Patients who met FDA-approved criteria were eval- laparoscopic gastric banding. uated by a multidisciplinary team preoperatively to determine their overall appropriateness for surgery.Dietary, exercise and P46.ESOPHAGEAL DILATATION FOLLOWING LAPARO- behavioral counseling were provided to all patients pre- and SCOPIC ADJUSTABLE SILICONE GASTRIC BANDING. postoperatively.Patients were followed for a twelve-month Dorothy R.Ferraro, MS, CS, ANP, Richard B.Rubenstein, MD, period following surgery;most were monitored monthly. Stuart Katz, MD. Private Practice, Caremax Wellness and Results:Thirty-one patients, aged 22 to 56, with a mean body Weight Management Center, E.Patchogue, N.Y., USA mass index of 47.4, underwent LASGB with the LapBand.Mean Background:Laparoscopic adjustable silicone banding duration of surgery was 187 minutes (range 88-355 min);none (LASGB) is currently being studied in the United States and has required open conversion.One patient underwent concomitant been in widespread use in Europe, Australia and Mexico for the cholecystectomy.Average length of hospital stay was 1.5 days. past several years.Complications associated with LASGB have There were no serious early postoperative complications.One been reported to include pouch enlargement, band slippage, patient was lost to follow-up.T wo patients developed late post- band erosion, infection (Belachew, 1998), and port or catheter operative complications requiring removal of the LapBand (one leakage (Miller,1999). Sugarman, 2000, reported esophageal with band erosion, the other with infection).The average excess dilatation in 72% of his patients following LASGB with the weight loss at twelve months was 37.6 percent (range 10-65%). LapBand.The purpose of this study was to analyze our experi- Conclusion:LASGB with the LapBand is a safe and effective ence with a group of LASGB patients and compare them to surgical option for the management of medically severe obesity. Roux-en-Y Gastric Bypass (RNYGB) and V ertical Banded Gastroplasty (VBG) patients with regard to esophageal dilata- P48.DISSOCIATION OF PLASMA LEPTIN CONCENTRA- tion.. TIONS WITH INSULIN AND BODY FAT 24 HOURS AFTER Methods:Twenty-seven patients were randomly selected LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING. from our practice.Preoperative upper GI series were compared Frühbeck G, Diez-Caballero A, Gó mez-Ambrosi J, Monreal I, to a follow-up study performed an average of one year postop- Salvador J, Cienfuegos JA. Depts.of Surgery , Endocrinology eratively.The radiological studies were independently analyzed and Biochemistry , Clí nica Universitaria de Navarra, Metabolic by a radiologist who determined the measurements and judge- Research Laboratory, University of Navarra, Pamplona, Spain ments regarding esophageal diameter, esophageal fullness, The adipocyte-derived hormone, leptin, has been shown to and stoma size.The esophageal diameter was measured in the decrease both food intake and body weight. Circulating leptin RAO and LAO views and an average of the two values was concentrations are associated with plasma insulin and body fat. determined.The radiologist provided an overall judgement of Gastric banding represents a surgical procedure designed pri- the esophageal size using a scoring system, and based this on marily to reduce food intake.The placement of an adjustable sil- his visual determination of the degree of esophageal fullness.A icone band in order to obtain a reduced stomach pouch has 30 percent or greater change in esophageal diameter was con- been reported to produce an early satiety sensation in patients

438 Obesity Surgery,11, 2001 Crete Abstracts undergoing gastric banding.The aim of the present study was COMPLICATIONS AFTER GASTRIC BANDING FOR MOR- to assess the potential involvement of acute changes in leptin BID OBESITY. concentrations following laparoscopic adjustable silicone gastric U. Winterberg, D. Wagner, H. Bockhorn. Chirurgische Klinik banding(LASGB). Krankenhaus Nordwest Frankfurt am Main, Germany The study groups comprised male patients undergoing either Laparoscopic gastric banding has become a common proce- LASGB (age: 46± 13 years; BMI: 43.0± 2.5 kg/ m 2; body fat: dure in bariatric surgery.Early as well as late complications are, 40.3±4.4%; n=7) or a comparable procedure regarding the sur- in comparison to conventional techniques, rare. Complcations gical approach as well as the time and kind of manipulations arising from the operative technique are:perforation,early pouch like laparoscop ic Nissen fundoplica tion and laparoscop ic dilatation, gastric slippage, infections of the port and the band, hernioplasty (Fd/ Hn) (age: 50± 8 years; BMI: 26.1± 1.6 kg/ m 2; erosion and defects of the band tube.Insufficent weight loss and body fat:27.8± 6.6%; n=6).Blood was withdrawn before surgery late pouch dilatation arise from unsatisfactory compliance on and 24 hours postoperatively for glucose, insulin and leptin the part of the patient.After 464 operations in 7,8 % reopera- measurements.In both experimental groups no statistically sig- tions were necessary.Obstruction of the pouch stoma and slip- nificant changes were observed in pre-and postsurgery glucose page resulted in total food intolerance.The management,diag- (LASGB:111± 8 vs 99± 6 mg/ dl;Fn/ Hn:107±7 vs 98± 5 mg/ dl) nosis and therapy of the common complications after gastric and insulin concentrations (LASGB: 39.8± 11.9 vs 32.9±10.3 banding is presented. U/l;Fn/Hn;13.2±3.3 vs 12.2±2.9 U/l).However , following surgery an increase in leptin concentrations was observed in the P51.LAPAROSCOPIC ROUX EN Y GASTRIC BYPASS WITH LASGB group(23.5± 4.7 vs 37.5± 6.8 _g/ l) whereas a small SILASTIC RING (CAPELLA´S PROCEDURE) IN THE TREAT- decrease was evident in the Fn/ Hn patients (12.9± 4.6 vs MENT OF MORBID OBESITY :EARLY RESULTS AND COM- 8.9±2.2 _g/ l).These findings strongly suggest that the short PARISON TO TECHNIQUE WITHOUT SILASTIC RING. term increase observed in plasma leptin concentrations follow- Thomas Szegö , MD, PhD ;Arthur B. Garrido Jr. MD, PhD; ing LASGB may play a key role in triggering an early satiety sig- Mitsunori Matsuda, MD, PhD.;Carlos José Lazzarini Mendes, nal due to the modification of the gastrointestinal anatomy and MD;Marcelo Roque de Oliveira, MD;Alexandre Elias, MD, Luiz physiology. Vicente Berti, MD . Private Practice - Albert Einstein and Beneficência Portuguesa Hospital, São Paulo, Brazil P49.UNILATERAL LOWER EXTREMITY COMPARTMENT The introductio n of laparoscop ic approach to bariatric SYNDROME FOLLOWING A LAPAROSCOPIC ROUX-EN-Y surgery brought similar advantages as seen in general surgery. GASTRIC BYPASS. A CASE REPORT. Performing Roux en Y gastric bypass according to the regular Piotr J.Gorecki, MD, Daniel Cottam, MD, L.D.George Angus, techniques however, showed less weight loss then achieved in MD, Ralph Ger, MD, Gerald W.Shaftan, MD. Nassau University the open procedure using silastic ring. In order to get similar Medical Center, East Meadow, NY, USA results as in open Capella´s procedure, the authors introduced Background:Obesity surgery has the potential for serious similar technique through laparoscopic aproach.Patients under complications.We present a case of unilateral lower extremity 55 in BMI are selected to open or laparoscopic procedure.The compartment syndrome after a laparoscopic gastric bypass per- author´s compare the early results of laparoscopic procedure formed in the modified lithotomy position. with and without silastic ring. Case report :A 38 year old female (weight - 134.5 kg, BMI – The results shows that the complementation of the operation 49.6) underwent a laparoscopic Roux-en-Y gastric bypass with silastic ring didn´t make the operation more difficult or time (operating time - 375 min). Following recovery from general consuming, didn´t increased complication rates and, in early fol- anesthesia the patient complained of bilateral lower extremity low up period, the patients had more regular and higher weight pain, which was subsiding and the patient was able to ambulate loss. on the night of surgery.On a postoperative day one, however, she developed a right leg compartment syndrome (compart- P52.MANAGEMENT OF BILIOPANCREATIC DIVERSION ment pressure – 71 mm of Hg). The patient underwent fas- COMPLICATIONS. ciotomy of the anterior and lateral compartments.Her pain sub- Santo Bressani Doldi, G. Micheletto, M. Perrini, E. Mozzi. sided and the small area of numbness on the dorsum of the foot Cattedra di Chirurgia Generale dell’ Università degli Studi di improved.On the following day , the patient was ambulating Milano - Istituto Clinico Sant’Ambrogio; Centro per la without difficulty and was discharged home on a fifth postoper- Farmacoterapia delle Malattie Nutrizionali e Metaboliche “E. ative day.By the 12th postoperative day her fasciotomy wound Genovese e R. Klinger”, Milan, Italy was closed with an assistance of a novel device (Proxiderm) by Background:In our Centre of bariatric surgery, active since applying a constant tension on the wound edges, which enabled 1974, we have never utilized the biliopancreatic diversion (BPD) delayed primary closure. The subseque nt recovery was for its incomplete reversibility and its surgical aggressiveness uneventful and her right leg recovered without any motor or sen- but, from the beginning of 80’s, we have hospitalized for severe sory deficits.At 4-months follow-up she had a weight loss of 28 complications 20 patients who underwent this procedure in dif- kg, stayed physically active and was overall satisfied with her ferent centres and in different times.Here, we report our expe- surgery.Potential pathomechanisms and risk factors are high- rience of management of BPD complications, particularly with lighted.Review of the literature is provided. reference to the last 7 patients treated in the last 3 years.All the Conclusion:Bariatric surgeons should be aware of this rare patients were operated on the same type of BPD. complication.Prevention and early recognition of this potential Methods:The patients are all females, mean age 42.5 years complication and prompt fasciotomy are crucial for favorable (25 – 47);mean weight pre-BPD 92.5 Kg (82 – 114);mean outcome. weight at the moment of hospitalization 65 Kg (55-89); mean BMI pre-BPD 35,6 (34 – 45);mean BMI at the moment of the P50.MANAGEMENT AND THERAPY OF POSTOPERATIVE hospitalization 25,3 (20 – 36);mean follow-up 9,5 years (2 - 17).

Obesity Surgery,11, 2001 439 Crete Abstracts

We observed these complications: insufficient weight loss (1 lost:50% after one year, stable through five years.Out of 1326 patient :from 91 to 89 Kg);excessive weight loss for persistent patients who underwent surgery from July 1995 through malabsorption ( 3 pts);severe osteomalacia for alteration of cal- December 2000, results for only 1106 patients were used (85% cium and vitamin D metabolism (2 patients), 1 with spontaneous women to 15% men, with a mean age of 41 years, and a mean pertrocanteric fractures;severe hypoproteinemia ( 7 pts );iron BMI of 43).The results were encouraging from the perspective deficiency anaemia ( 6 pts). One patient had numerous of weight loss expressed as a percentage of excess weight: haematic transfusions; severe and late dumping syndrome (1 45% after one year for 950 patients followed out of 1106;43% pt);halitosis (3 pts); persistent diarrhea more than 5 evacua- after two years for 371 patients followed out of 742;41% after tions/day (1 pt);liver failure (1 pt).Six patients were treated with three years for 145 patients followed out of 355;48% after four hyperproteic and hypercaloric parenteral nutrition (PN), and years for 30 patients followed out of 101.The efficacy of Gastric with polyelectrolytes and polyvitaminics endovenous infusion for Banding seems more limited when the initial BMI is greater than more than 60 days, in the hospital and/or at home, till to gain an 50 (approximately 40% after one year, sustained for four acceptable metabolic balance.We have converted 3 patients to years?). adjustable gastric banding according to Kuzmak and 2 patients Of all complications, two types seem the most serious:slip- had reversal;the others are still under medical care. page, 11% in our series, and migration, 0.3% in our series.The Results:Hyperproteic and hypercaloric parental and oral frequency of each of these complications seems to vary, nutrition obtained in all patients a good metabolic balance. depending on the type of band and the placement technique. Three patients didn’t achieve a stable metabolic balance at the Slippage is most frequent with the LAGB (up to 18%).We had end of PN so that it was necessary a reversal of BPD or con- 129 cases of slippage out of 1090 surgical cases using the version to adjustable gastric banding in accordance with the LAGB with the original technique (11%), seven of which under- patient, the internist and the psychologist. One patient had went two repositioning procedures.All of these cases required reversal for psychological indication.Post-operative course was laparoscopic reoperation for repositioning the band, including all uneventfull for 2 patients;1 patient had an acute hemorrhagic cases where the band was opened, not opened or replaced. gastritis in the first post-operative day, treated with medical care. This complication rate had no specific peak during the post-sur- One patient had a revision for intestinal occlusion.The patient gical period.There were 0.3% to 5% of such cases of slippage who had an insufficient weight loss after BPD, had a good result each month, commencing in the first month post-surgery. after adjustable gastric banding (from 89 to 70 Kg, BMI 25).The Migration is most frequent with the SAGB (up to 4.6%).This other patients had an increase of 20 Kg one year after reversal. band has a balloon that rolls up in the event of “overinflation,” Conclusion:Our experience permits to underline that:1) BPD and allows the sharp edge of the band to come in contact with can be better used in the morbidly obese patients with BMI > 40; the visceral layer, creating a point of friction, whence the possi- 2) the choise of the patients must be careful, particulary by psy- bility of erosion. We had three cases of delayed intragastric chological point of view;3) BPD requires a continous, constant migration (0.3%) through the anterior stomach wall. These and rigorous follow-up to prevent or to opportunely treat the occurred with the first generation LAGB, from month 36 through metabolic complications such as all malabsorption bariatric pro- month 40, which eliminates any etiology related to dissection cedures.These all complications can be successfully traited too close to the posterior stomach wall. medically or surgically; 4) BPD doesn’ t permit the complete With all other systems – 10.0 LAGB in the pars flaccida posi- reversibility because of gastrectomy but only a partial functional tion (103 surgical patients), 11.0 LAGB with a wider balloon in one;5) the metabolic complications and the failures of BPD can the pars flaccida position (123 surgical patients), SAGB also in be treated by conversion into adjustable gastric banding. the pars flaccida position (105 surgical patients), PIER system (2 surgical patients), i.e., a total of 333 patients – we have had P53.PRELIMINARY STUDY CONCERNING A SINGLE INSTI- no more slippage for one year, while with the LAGB using the TUTION’S EXPERIENCE WITH 1410 CASES OF original technique, 27 removals were required due to slippage. ADJUSTABLE GASTRIC BANDING PERFORMED FROM By comparing the different materials, their design and posi- JULY 1995 TO APRIL 2001,(5-year retrospective). tioning, the authors endeavor to suggest an explanation for Jean-Marie Zimmermann, Michel Blanc, Pierre Mashoyan, Érick these complications.The mortality from this series was 0.7 per Zimermann, Jean-Marc Grimaldi. Clairval Private Hospital thousand, which makes this method of Gastric Banding the Center, Marseille, France. least aggressive of all the recommended surgical techniques, The authors present a review of their experience with especially if we take into account the risk-to-benefit ratio. Adjustable Gastric Banding, commencing in July 1995, after ten years of practicing both conventional VBG and laparoscopic P54.BARIATRIC SURGERY COMPLICATIONS WITH bariatric surgery, from 1985 to 1995.From this experience, they ADJUSTABLE LAPAROSCOPIC GASTRIC SYSTEM (LAP derive a different approach for the future. From July 1995 BAND). PREVENTION AND TREATMENT. through April 2001, 1410 patients underwent surgery. The Carlos Alberto Casalnuovo, Ezequiel Ochoa de Eguileor, series meets the same criteria as the series in the literature: Gustavo Parrilla, Eduardo Liljesthrö m. Hospital de Clí nicas, mean age 41 years (17- 65), mean BMI 43 kg/m? (35-80), mean University of Buenos Aires, and Private Practice (CCO-Centro weight 114 kg (83- 230), mean excess weight 43 kg, 85% de Cirugía de la Obesidad), Buenos Aires, Argentina women to 15% men, and 174 patients with a BMI greater than Background:Laparoscopic adjustable gastric banding is con- 50 (14.1%).The materials used were 1090 LAGB (original tech- sidered as a good and safe operation and is an attractive alter- nique), 105 SAGB, 103 LAGB (pars flaccida technique), 123 native for patients who can benefit from a simple restrictive LAGB (11 cm.), 2 PIER systems.A total of 1423 gastric bands bariatric procedure. were placed, due to removal and replacement of materials (15 Nevertheless, complications may occur, and therefore standars cases). and strategies in the prevention and treatment of complications The results are expressed as a percentage of excess weight should be defined.

440 Obesity Surgery,11, 2001 Crete Abstracts

Methods:From January 1998 - January 2001 we placed etiology of band erosion / migration. Laparoscopically 150 adjustable gastric banding (Lap Band). The mean preop.BMI was 52.8 (35-89.3).The 56% had a BMI P55.CHANGED EATING BEHAVIOR PRODUCED BY =/>50 (SO, SSO, TO) and 12% =/> 66 (triple obese) CHRONIC BILATERAL VAGUS NERVE STIMULATION. The complications found were analyzed and divided into M.S.Roslin, R.Reddy*, S.M. Parnis**, B.T.Barrett**. Lenox Hill intraop, early and late postop. Hospital, New York, NY, *Maimonides Medical Center, Brooklyn, Results:During the operation, 4 (2.7%) bleeding trocar NY, **Cyberonics, Inc, Houston, TX, USA wounds, were easily treated with electrocautery or suture; Background:Obesity is one of the most prevalent diseases in 1 proximal tube fracture was repair with metal connector; 1 the western world.However, treatment options remain less than abdominal esophageal tear (4cm) for inopportune calibrating optimal.Previous reports have suggested the importance of the balloon inflated in wrong place by the anesthesiologist, could be vagal afferents in the transmission of satiety signals from the gut sutured laparoscopically with good result.In the early stage of to the brain. The aim of this study was to determine whether the postop.: 1 hemopenritoneum needed a relaparoscopy at vagus nerve stimulation (VNS‰ ) using the NCP ® System 48hs.for a slight bleeding trocar wounds;1 patient with acute (Cyberonics;Houston, Texas) could alter eating behavior and pulmonary edema, needed artificial ventilatory support from the result in weight loss in a canine model. surgery until 72hs.; 2 minimus biliary hipertension syndrome, Methods:From September 1998 to March 2000, a total of one (cholecystectomy as simultaneous associate procedure for eleven studies were performed in a canine model. Bipolar gallstone) have been resolved with ERCP one week later.The Leads were placed on the distal bifurcating vagal nerve trunks other one, developed it at the end of the 1st month, have been in the subdiaphragmatic (1/11) and in the supradiaphragmatic a spontaneous resolution (biliary sludge);4 (2.7%) port infection (10/11) position.In the supradiaphragmatic series, two studies (7 – 15 days postop.). The 1st patient presented 2 recurrent (2/10) were performed using programmed stimulation parame- abdominal wall abscess even after port removal (3m postop.), ters that delivered electrical signals 30 minutes before and dur- and 12 months after we decided ralaparoscopy far away from ing meal consumption time only (acute stimulation).Eight stud- septic zone and turning away the tube with a segment added to ies (8/ 10) were conducted with the programmed stimulation the opposite part of the abdomen wall.A early relaparoscopy (2- parameters delivered in various duty cycles continually through- 3m) with port removal was done to the 2nd and 3rd patients and out the day (chronic stimulation). in one of them a simultaneous new port was placed. The 4th Results:Eating behavior was significantly altered during the patients we give up the tube into the abdomen with end plug for chronic stimulation studies, with increased consumption times protrusion of it.Segment of the tube in the section area were and reduced consumption amounts. No clinically significant taken for culture with negative results, as negative endoscopies changes were seen in hematologic or biochemical blood pro- in all patients for erosions. files.No pulmonary or cardiac problems were encountered in As late complications we found 2 slippages (1.3%). One any animal during the study.Upper gastrointestinal endoscopy anterolateral, acute, 4 _ months after operation, with clinical and studies performed at the conclusion of the chronic studies radiological diagnosis with the ring moving to inverted position showed no abnormalities in esophagus, stomach or duodenum. was reduced by relaparoscopy under the band, and new line of Compared with the normal vagus trunk of the dog, the vagus fixation sutures were used.The posterior slippage (perigastric nerves of study animals showed no clinical gross or histopatho- technique in primary operation) was developed 12m postop., ini- logic changes. tially controlled by band deflation, but the re-banding by rela- Conclusions :During chronic stimulation, distal VNS can alter paroscopy in a higher level was carried out 4 months later.One the eating behavior of the dog. patient with leakage from band-balloon was re-banding 3 months postop by relaparoscopy .Another patient (0.7%) with P56.COMPARISON OF DIFFERENT TECHNIQUES OF gastric erosion, 9 months after operation, was debanding by LAPAROSCOPIC PLACEMENT OF ADJUSTABLE GASTRIC relaparoscopy.The total reoperation rate by relaparoscopy for BANDS. major complications, including 3 port infection, was 5.3% (8 R.Weiner, D. Wagner, R. Blanco-Engert. MIC-Zentrum patients).There was no mortality. Frankfurt-Sachsenhausen, Frankfurt a.M., Germany Conclusions :Laparoscopic adjustable gastric banding seems A randomized prospective study was constructed in order to to be a safe and satisfactory procedure with a low rate of com- determine whether laparoscopic esophagogastric placement plications._ It requires a very strict patient follow up and a good (EGP) is associated with lower incidence of postoperative SP selection._ Most of the reoperations can be performed by rela- and pouch dilation than after retrogastr ic placemen t paroscopy._ It is necessary, strict control of the trocar wounds RGP.Morbid obese patients presenting for LAGB were random- before the operation end, to avoid contingent hemorrhages._ ized to undergo either an EGP (n=50) or a RGP (n= 51). With “ pars flacida” modification we decrease surgical time, a Patients were blinded to which procedure had to be performed, more simple dissection in superobese patients and higher and and follow-up was obtained by a blinded independent investiga- stable position of the band, avoiding posterior slippage._ It is tor.Standardized clinical and radiological controls were used to very important exactly fixation of the stomach over the band to asses pouch enlargement and SP.Operating time was similar for prevent anterior slippage._ Always must be tested the balloon the two procedures (54,5 min for the EGP versus 58 min for before placed the band, to recognize unexpected band defects. RGP). There was no significant difference in postoperative _ It is not recommended to do a simultaneous cholecystectomy weight loss (34 kg after EGP versus 37 kg after RGP within 12 as associated procedure, except that the patient has syntomatic month), esophagus dilation or postoperative quality of life.There gallstones._ A good alternative in port infection is an early turn- was one postoperative SP and one pouch dilation in the RGP ing away the tube to an aseptic area with or without new port group versus no postoperativ e complicati on in the EGP implant._ The recurrent infection of the port area may be fol- group.Conclusions:The placement of LAP-BAND in EGP-tech- lowed by tube / band contamination that could be involved in the nique is safe and followed by a lower frequency of postoperative

Obesity Surgery,11, 2001 441 Crete Abstracts complications, than in RGP-technique. Clear anatomical land- superior weight loss should be further analyzed considering the marks are a benefit to education and learning curve of LAGB. devastating effects of smoking. Smoking probably should be used as a predictor of weight loss after bariatric surgery and P57.MINIMALLY INVASIVE REINTERVENTIONS TO TREAT should also be taken in consideration in expressing weight loss COMPLICATIONS AFTER BARIATRIC SURGERY. results, specially in countries where smoking is more prevalent. F.Aigner, MD., H.Weiss, MD., H.Nehoda, MD., H.Bonatti, MD. Univ.Hospital of Surgery, Dep. of Gen.Surg., Innsbruck, Austria P59.SOLID STATE BARIUM MEAL IN LAP-BANDS Background:Bariatric operations are mostly performed INSERTED WITH PARS FLACIDA TECHNIQUE. laparoscopically, but also by open surgery.Nevertheless most of Marina S.Kurian, MD, and Mitchell S.Roslin, MD. Department the reoperations can be done also by laparoscopy. of Surgery, Lenox Hill Hospital, New York, NY., USA Methods:Between 1.1.1996 and 31.3.2001 in 383 patients Background:Laparoscopic adjustable gastric banding has with bariatric operations we had to operate on 79 complications. been performed worldwide for several years.Conventional wis- 31 reinterventions were done in local anesthesia due to port- dom states that the band creates a pouch and eating causes complications, 6 cases of intragastric bandmigration were man- mechanical distension of the pouch with cessation of food aged gastroscopically and 39 laparoscopic reinterventions in 29 intake.T o explore the mechanism of early weight loss in patients patients were necessary due to different reasons. who underwent band placement we performed solid-state bar- Results:Only in 3 cases of gastric perforation the reinterven- ium meals prior to any adjustment. tion has to be done by laparotomy.The most common laparo- Methods:Four LAP-BAND patients underwent insertion of a scopic reoperation was to renew the band within one session in 9.5 sized LAP-BANDs using the Pars Facida technique.Bands 17 cases (leckage of the band in 9 cases, stoma narrowing with were not inflated.A barium meal (bagel soaked with barium) pouchdilatation due to too small banddiameter in 8 cases).All 6 was performed under fluoroscopy 5 to 6 weeks post operatively. cases of late pouchdilatation could be corrected laparoscopi- Mean weight loss at this point was 17 pounds with a range of cally without bandexchange, 6 times we removed the band 9 to 24 pounds. Images were taken with solid ingestion until laparoscopically on desire of the patients (4 cases with late satiety or dysphagia was reported. dilatation.2 cases without complication ).We put in a new band Results:With the band left uninflated, we saw no delay in several month after removing the old one in 4 patients due to dif- passage of solid material with satiety or dysphagia. ferent reasons (1 migration, 1 infection, 2 perforations), and 3 Conclusion:The absence of delay in passage of solid mater- times we had to recover an intraabdominal tubedislocation after ial indicates that gastric distension of a small pouch is not the tuberupture.2 patients with VGB recived an adjustable gastric cause of early weight loss in bands placed through the Pars band, one VGB was removed, all on laparoscopic way. Flacida technique. Instead, our data supports the hypothesis Conclusions :Most complications after bariatric surgery in our that a proximally placed band inhibits receptive relaxation, and series could be managed by minimally invasive techniques such rapid food ingestion causes dysphagia.Consistent with this are as local, endoscopic or laparoscopic methodes,even when the reports that bands placed at the Pars Flacida require fewer first operation was done by laparotomy (6 cases).Only in three adjustments.Further investigation with additional patients, and patients (<1%) with gastric perforation we had to perform an comparative studies with patients with more distally placed open operation. bands are necessary to understand how the Lap-Band changes eating behavior and how this varies with the location of the P58.INCIDENCE OF SMOKING AND WEIGHT LOSS IN OUR band. BARIATRIC POPULATION. Joseph F .Capella, MD., Rafael F .Capella, MD . Hackensack P60.THE INFLUENCE OF GASTRIC BANDING ON PLASMA- University Medical Center, Hackensack, New Jersey, USA AMINOXIDASE (PAO) - A POSSIBLE PROGNOSTIC FACTOR Background:An estimated 33% of the world’ s populations IN OBESITY ASSOCIATED MORBIDITY. age 15 and above smoke regularly.Along with obesity, tobacco J.Klocker, B. Labeck, H. Nehoda, F .Aigner, A. Klingler, C. is one of the major world health problems.In this study we ana- Ebenbichler, B. Fö ger, M. Lechleitner, H. Schwelberger, H. lyzed the incidence of smoking and weight loss in our bariatric Weiss. Departments of General Surgery and Internal Medicine, population of 1060 patients that underwent V ertical-Banded University Hospital Innsbruck, Austria Gastroplasty-Gastric Bypass. Background:Increased activities of PAO, an enzyme convert- Methods:All patients undergoing this type of surgery coming amines, have been implicated in the generation of endothe- pleted a questionnaire that encompassed smoking habits.They lial damage through formation of cytotoxic reaction products.We were divided in A=nonsmoker, B=less than half a pack, C=one investigated if P AO activities are elevated in morbidly obese pack daily and D=more than one pack daily .An overall inci- patients which might contribute to the increased cardiovascular dence of smoking and percentage excess weight loss at three risk and if adjustable gastric banding has impact on PAO activi- years were analyzed. ties. Results:The incidence of smoking in this group of patients Methods:45 patients underwent laparoscopic adjustable gas- was less than the population in general.Only 17% of patients tric banding (SAGB ®, Obtech;median BMI 44.4 kg/m2).P AO have contact with tobacco and only 2.5% smoked more than activities were determined (radiometric assay , normal value one package daily .Excess weight loss was superior in all <450µU/ m) pre- and postoperatively (245±105 days).32 healthy groups of smokers as compared to nonsmokers. A=73%, volunteers (median BMI 23.3 kg/m2) served as controls.In addi- B=79%, C=79% and D=84%. Despite the small number of tion parameters of glucose and lipid metabolism were deter- smokers, the results were statistically significant when Group A mined and compared for subgroups of obese patients with nor- was compared to group B (p>0.05) and D (0.03). mal and impaired glucose metabolism and with diabetes. Conclusions :Fortunately, our bariatric patients appear to Results:Morbidly obese patients showed significantly higher smoke less than the general population.The miss blessing of PAO activities than control subjects (431 versus 361µ U/ ml).

442 Obesity Surgery,11, 2001 Crete Abstracts

After adjustable gastric banding significant reduction of BMI P62.HEMODINAMIC AND CARDIAC FUNCTIONAL (p<0.001), fasting glucose levels (p<0.001), insulin (p<0.001), IMPROVEMENTS AFTER SURGICAL TREATMENT OF C-peptide (p<0.001), lipids (p<0.05) and P AO activity SEVERE OBESITY. (371µU/ ml, p<0.001) could be observed.P AO activities were not F.Mittempergher, D .Moneghini, B. Salerni, S. Nodari*, A. correlated with any clinical or metabolic parameter in obese Madureri*, L.Dei Cas*. Chair of General Surgery and * Chair of patients pre- or postoperatively. Cardiology, University of Brescia , Italy Conclusion:Elevated P AO activities are found in morbidly It is well known that alterations in the left ventricular (LV) func- obese patients as an independent risk factor for obesity-related tion occur in patients with severe obesity.Heamodinamic, meta- morbidity.Adjustable gastric banding resolves impaired P AO bolic, hormonal and neurovegetative changes may recover after activities and improves the metabolic vascular risk profile. weight loss. We evaluated the haemodinamic and functional changes induced by weight loss after surgical treatment (bil- P61.OUR CHANGING APPROACH TO THE PROPHYLAXIS iopancreatic diversion, vertical gastroplasty) on patients with OF VENOUS THROMBOEMBOLISM IN BARIATRIC severe obesity (body mass index, BMI>35).Fourthy patients (30 SURGERY. females, 10 males), aged 41 ±9 years (range 21-60), BMI 45 ± Maria Laura Cossu, Enrico Fais, Matteo Ruggiu, Claudio 7 (range 36-72), weight 135 ±28 Kg, were evaluated before and Sparta, Franca Cossu, Giuseppe Noya. Department of after 30% weight loss caused by surgical therapy.We examined Emergency Surgery, University of Sassari, Italy. the changes in blood pressure and heart rate, the electrocar- Background:Morbidly obese patients undergoing bariatric diogram (electric axis, signs of LV hypertrophy, atrio-ventricular surgery have commonly been considered to be at high risk of conduction and repolarization), Holter monitoring (maximal-min- developing perioperative venous thromboembolism.Due to its imal-mean heart rate, ventricular and supraventricular ectopic clinical silent nature , primary prevention is the key to reducing beats), and the echocardiogram (L V volumes and diameters, morbidity and mortality. parietal thickness, fractional shortening, ejection fraction, and Method:Between February 1995 until February 2001, 144 E/A ratio). obese patients underwent bariatric surgery: In 134 patients At baseline 8 patients were affected by hypertension on phar- (mean preoperative weight and BMI: 135.28 Kg- 51) we per- macological treatment.The electrocardiogram showed left axial formed biliopancreatic diversion.43 cases (32.8%) had associ- deviation in 85% of the patients and signs of left ventricular ated diabetes type 2 and 16 cases (12.2 %) had IGT .In 74 hypertrophy in 35%. The echocardiogram showed normal L V cases (56.4%) serious alterations of lipidic metabolism were diameters, volumes, fractional shortening and ejection in all the present.In 10 patients ( mean preoperative weight and BMI: patients.L V hypertrophy was present in 18 patients and all 120.9Kg - 41.22) we performed VBG. Two of these patients showed an abnormal filling pattern with an E/A value of 0.8 ±1. (20%) had associated diabetes type 2 was associated and in 3 Holter monitoring showed supraventricular and ventricular had a slight hypercholesterolemia.At beginning of our experi- ectopic beats of moderate frequency in 8 and 11 patients, ence, in the first 65 cases, during the operation a dose of respectively (0.4 ±0.7 VPB/24 hours and 0.8 ±1.2 SVPB/ 24 heparin was administered endovenously (one shot of 2500- hours). 3000 Ul), immediately after anesthetization, as a safeguard Surgical therapy caused a reduction in BMI from 45 ±8 to 40 against thromboembolism.The patient’s lower limbs were ban- ±8 and in body weight from 135 ± 28 Kg to 105 ± 20 Kg daged and early ambulation was resumed in the first six hours (p<0.001 in both cases) with a concomitant reduction in heart after the operation. In the later period of our experience, (79 rate (from 78 ± 11 to 65 ± 12 b/min, p<0.05), diastolic blood cases), we changed the prophylaxis and in association with pressure (from 79 ± 10 to 72 ± 6 mmHg, p<0.05) and mean compression stoking and early ambulation, we began to admin- heart rate at Holter monitoring (from 80 ±9 to 66 ±10 b/min, ister low- dose sc heparin.The dosage (min 20.000 UI /die max p<0.001).The echocardiogram showed a significant reduction in 35.000 UI /die divided in two administrations) was usually stabi- LV end-systolic diameter from 31 ±3 to 27 ±4 mm (p<0.05), LV lized by testing the coagulation time and coagulation factors end-systolic volume from 36 ±10 to 28 ±8 ml (p<0.05), inter- every day so to achieve a good anticoagulation.This treatment ventricular septal wall thickness from 11 ± 2 to 9 ±2 mm usually started 4-5 days before operation and continued until (p<0.05) and posterior wall thickness from 11 ±2 to 9 ±1 mm discharge (7-8 days after operation) . Low doses sc heparin (p<0.05) with an increase E/ A ratio from 0.8 ± 1 to 1.4 ± 2 (usually 5000-7500 UI x2/ die) were administered after dis- (p<0.05). charge for 7-10 days. In conclusion, severe obese patients treated by surgery can Result:In the first group of patient we observed 2 cases (3%) obtain, at 30% of weight loss, a significant reduction in heart of acute pulmonary embolism on the 1th -2nd postoperative rate, diastolic blood pressure, L V end-systolic diameters and days which was the immediate cause of death.In the second volumes, and wall thickness with an improvement of the LV fill- group 1 case (1.2%) of non- fatal pulmonary embolism occurred ing pattern and overall function. on the 15th postoperative day :a urokinase injection in the main pulmonary artery led the thrombosis resolution. P63.LAPAROSCOPIC GASTRIC BANDING IN THE Conclusion: It is widely accepted that morbidly obese ELDERLY. patients are at high risk of developing perioperative throboem- H.Nehoda, MD;K.Hourmont, MD;T .Sauper, MD;R.Mittermair, bolism and the majority routinely undergo prophylaxis.There is MD;M. Lanthaler,MD;F .Aigner, MD;H.Weiss, MD. Department no clear consensus in the literature regarding the optimum of General Surgery, University Hospital of Innsbruck, Austria approach to minimize this preventable phenomenon.Our expe- Hypothesis:Elderly patients experience the same benefits rience suggests that a "personalized heparin prophylaxis " from a laparoscopic gastric banding operation (LGB) as do before, during and after bariatric surgery could be the key to younger patients. reduce morbidity and mortality. Design:A case series of 320 morbidly obese and superobese patients who underwent laparoscopic gastric banding (LGB)

Obesity Surgery,11, 2001 443 Crete Abstracts within a 46-month period. Conclusions :The high incidence of gallbladder disease in Patients:A consecutive sample of 320 patients who met the morbidly obese patients in general, in combination with the high criteria for a bariatric procedure and were 18 years or older. incidence of cholelithiasis after bariatric surgery and the diffi- Patients were divided into the following two groups: younger culties in the laparoscopic management, lead us to conclude patients (between 18 and 49 years old) and elderly patients (50 that cholecystectomy should be performed in all morbidly obese years or older). patients concomitently with bariatric surgery. Intervention :Laparoscopic gastric banding (LGB) with the Swedish adjustable gastric band (SAGB, Obtech Switzerland). P65.IMPROVEMENT IN METABOLIC CO-MORBIDITI ES Main Outcome Measures :Clinicopathologic features includ- FOLLOWING WEIGHT LOSS FROM GASTRIC BYPASS ing weight loss, complications, length of hospital stay, operative SURGERY. times of these patients were reviewed retrospectively and a mul- Richard S Stubbs. Wakefield Gastroenterology Centre, tivariate analysis carried out. Wellington, NZ Results:Of 320 patients, we identified 68 (21.5%) elderly Background:Clinical observation reveals a close association patients.The mean postoperative follow-up period was 12 between morbid obesity and a variety of serious medical condi- months (range: 6-28). The average preoperative weight was tions.This report describes the changes observed in some of 127.8kg (BMI 44.29 kg/m2).The average total weight-loss was the co-morbid conditions commonly associated with morbid 4.3 kg per month, reaching an average total of 28 kg after one obesity following the weight loss achieved by silastic ring gastric year.The excess weight loss (EWL) after 12 months was 68%. bypass (SRGB). Complications requiring reoperation occurred in 10.3% (vs. Methods:Between 1990 and 2000, 259 morbidly obese 7.3% in the younger group). Ninety-seven percent of the patients (60 M, 199 F) aged between 15 and 68 years under- patients reported an improvement in their co-morbid conditions. went SRGB. Initial and follow-up data was recorded prospec- Conclusions :Elderly patients receive the same benefits from tively on a computerised database, with minor subsequent addi- LGB as younger patients, although they have a slightly higher tions being achieved by phone call or questionnaire. postoperative complication rate (3.0%). Presently, our upper Results:Median pre-operative BMI of the group was 44.5 (33- age limit is 70 years. 78).Patients were followed for a minimum of 2 years, at which time median BMI was 28 (20-52). Prior to surgery we noted P64.ROUTINE CHOLECYSTECTOMY CONCOMITENT WITH hypertension in 91 (35%) patients, Type 2 diabetes in 37 (14%), BARIATRIC SURGERY: ISITNEEDED? abnormal glucose tolerance in 48 (19%), dyslipidaemia in 139 Papavramidis Spiros, Sapalidis Konstantinos, Deligiannidis (54%) and hepatic steatosis in 232 (90%).Following surgery no Nikolaos, Papavasiliou Ilias, Gamvros Orestis. 3rd Surg.Dept. patient with prior impaired glucose tolerance has become dia- AHEPA Hosp. Aristotelian University of Thessaloniki, Greece betic, and 33 of those with diabetes are no longer diabetic. Background:Routine cholecystect omy concomitent with There has been resolution of hypertension in 51 and improve- bariatric surgery is controversial. This study documents more ment in a further 27.Hypercholesterolaemia which was present clearly the gallbladder disease of morbidly obese patients who in 137, normalised in 50 and improved in a further 43. underwent bariatric surgery (vertical gastroplasty). Hypertriglyceridaemia which was present in 96, normalised in Methods:A total of 220 consecutive morbidly obese patients 59 and improved in another 6.T otal cholesterol/HDL chol which (BMI > 40Kg/ m 2), who were treated by vertical gastroplasty was elevated in 139, normalised in 76 and improved in a further between 1990 and 1999, were included in the study .Patients 22.Hepatic steatosis improved in 21/28 patients in whom repeat were divided in two groups.Group A consisted by 120 consec- liver biopsies were available. utive patients (1990-1994), 29 male and 91 female with a mean Conclusions :Our findings indicate substantial weight loss is BMI=53±10 Kg/m 2, who were managed by routine cholecystec- accomplished by gastric bypass surgery with accompanying tomy concomitent with vertical gastroplasty.Group B was com- major reductions in the associated metabolic co-morbidities. posed by 100 consecutive patients (1995-1999), 38 male and 62 female with a mean BMI=52,3± 10 who underwent vertical P66.NORMAL BODY WEIGHT IS THERE A REALISTIC gastroplasty without routine cholecystectomy. CHANCE AFTER BARIATRIC SURGERY? Results:Ten patients (8,3%) of group A, and 2 (2%) of group B.Husemann, Th. Sonnenberg. Dominikus-Krankenhaus P.O. B had undergone cholecystectomy before bariatric surgery . 290151, D-40528 Dusseldorf/ Germany Ninety seven percent of the removed gallbladders of group A To calculate the questions, whether morbid obese patients had gross or histologic abnormalities including cholelithiasis can reach and keep normal body weight after bariatric surgery 22,5% (27 patients), cholesterolosis 21,6% (26 patients), sludge or not is very important not only for the patients but also for life 10,8% (13 patients) and chronic cholecystitis only 41,6% (50 insurances and social services. We have analysed our own patients).T wenty-five patients of group B (25%) underwent patients 60 month after VBG (n = 91) and lap band (n = 37).The cholecystectomy because of preoperative and intraoperative prae-op body weight demonstrates the morbid obesity with a diagnosis of cholelithiasis and additional one (1%) because of BMI of 49,1 respectively 47,2 kg/m 2.After five years 46,2% or adenomyosis.From the 72 patients of group B with an intact 43% of all operated patients have a body weight below 30 kg/m 2 gallbladder, in 26 patients (36%) a symptomatic cholelithiasis and 17% respectively 21% under 25 was developed within two years after bariatric surgery , and a kg/m2 or normal weight.However, 29% or 26% are above a BMI laparoscopic cholecystectomy was performed in all of them, of 35 kg/m2.The reasons are different: One third of these which was reverted in open in 6 cases (23%).In group B the patients are sweet eaters and one third shows abnormal eating BMI of the patients with cholelithiasis was significantly greater behaviour with sweet, high caloric soft drinks. By 7 patients than that of patients with cholecystitis.In group B the patients oesophageal pooling seems to be the reason for the insufficient who developed cholelithiasis after gastroplasty had not signifi- weight loss.Therefore, bariatric surgery alone would be insuffi- cantly greater BMI than those without disease. cient, there is necessary a training for eating, chewing and

444 Obesity Surgery,11, 2001 Crete Abstracts cooking, too. We suggest a prae-operative psychosomatic nosed with phlebography several weeks after discharge and 1 check up, to evaluate the eating behaviour and to adapt the sur- (0.35%) patient was presented 3 weeks postoperatively with a gical procedure. angiographically diagnosed minor pulmonary embolism.Further investigation proved an unknown activated protein C resistance. P67.PATIENT CHARACTERISTICS INFULENCING WEIGHT One (0.35%) patient died 4 days postoperatively and the post- LOSS FOLLOWING LASGB-OPERATION. mortem examination revealed a pulmonary embolism as a pos- Ralph Peterli, Y ael Anner, Peter T ondelli. Surgical Clinic, sible cause of death.This patient had a Prader Willi condition. St.Claraspital Basel, Switzerland The patients (116/285) participating in Duplex scanning had no Background:There is a controversy whether the laparoscopic symptomatic thromboses.However, the scanning revealed two adjustable gastric banding operation (LASGB) as a purely thromboses in one of the calf veins in two patients (0.7%) and restrictive bariatric procedure is indicated in some patients one patient (0.35%) with a thrombus in the long saphenous (sweets eaters, superobesity).We investigated the influence of vein.These 3 patients were treated with 40 mg enoxaparin daily preoperative patient parameters (BMI, gender, eating behavior and at repeated scanning after one week the thrombi were etc.) on weight loss by performing LASGB as the primary inter- resolved. vention in all morbidly obese patients. Conclusion:Tromboembolic complications after RYGBP is Methods:Between 12/96 and 5/00 LASGB was performed in uncommon in this study;1.4% DVT including asymptomatic calf 164 patients (84% female) with an average body weight of 127 thrombosis and 0.7% PE including one fatal. (91-250) kg, BMI of 45 (33-75) kg/m2, aged 40 (17-64) years. All patients were prospectively evaluated and followed using a P69.LAPAROSCOPIC BILIOPANCREATIC DIVERSION standard protocol after a mean of 18 (4-48) months.All patients WITHOUT GASTRECTOMY. remained in the study including such with pregnancy during the Joaquin Resa. Hospital Royo Villanova. Zaragoza, Spain. postoperative course, re-operations or failure. Biliopancreatic diversion is a very effective procedure and Results:The average excessive weight loss was in the 1st has been successfully used as one of many surgical treatments year 46% (n=120), in the 2nd 50% (n=57), in the 3rd 57% to achieve significant long term weight loss.This idea lead us to (n=16) and in the 4th year 43% (n=1).A better weight loss could perform bilipancre atic diversion by using a mini-invasi ve be observed in women, in patients without the feeling of satura- approach.T o reduce laparoscopic Scopinaro difficulty we avoid tion preoperatively, with successful weight loss under conserva- the gastrectomy.Our procedure consists of a proximal gastric tive treatment (more than 20 kg), in patients without regular transection with a long Roux-en-Y reconstruction (Video pre- intake of sweets and without snacking. Some sweets eaters sentation). stop eating sweets after LASGB others develop this eating dis- Patient in the supine position with head-up tilt with the sur- order de novo. Patients with a preoperative BMI > 50 kg/ m2 geon operating on the left and the assistant between the legs of showed less weight loss initially but after 3 years no such differ- the patient.The main monitor should go at the head of the table. ence could be found. No correlation could be demonstrated The laparoscope is first placed through an umbilical port (10 between weight loss and education, patient number and big mm) and initial inspection of the peritoneal cavity performed.We eaters. favors a 30-degree forward-oblique viewing laparoscope T wo Conclusion:Some patients (sweets eaters, male gender) additional left upper quadrant trocars (12 mm) and a right upper loose less weight after LASGB but the prognosis cannot be quadrant trocar (12 mm) are placed under direct vision. made in the individual case.Superobesity does not seem to be In order to create the Roux-limb, the jejunum is divided 200 cm a contraindication for LASGB. beyond the caecum by using an Endo GIA, 45 mm long with 3.5 mm staples. In addition the mesentery is divided with a har- P68.POSTOPERATIVE THROMBOEMBOLIC COMPLICA- monic scalpel.The Roux-limb is measured from caecum to 50 TIONS AFTER OBESITY SURGERY. cm in ileon length. An side-to-side anastomosis between the A Westling MD, Ph D & S Gustavsson Assoc prof. Department proximal jejunum and the Roux-limb is created by firing a Endo of Surgery University Hospital Uppsala, Sweden GIA II staplers. The enterotomy is closed using a continuous Background:Obesity is often claimed to be a risk factor for suture. postoperative thromboembolic complications.The incidence of A retrogastric-retrocolic tunnel is performed in the mesocolon postoperative deep venous thrombosis (DVT) after obesity anterior and lateral to the ligament of Treitz. surgery is incompletely known. The stomach is sized to a small pouch.The site of incision is Methods:During 1996-2000 we have performed 285 Roux- determined at the greater curvature and performed a retrogas- en-Y gastric bypass procedures (RYGBP). In 94 patients tric tunel. Select the proximal transection site, the Endo GIA (median BMI 38 kg/m 2) RYGBP was a revisional procedure after stapler, 45 mm long with 3,5 mm staples is then fired three previous failures with VBG and banding procedures. 191 times as shown horizontaly. patients (BMI 44 kg/ m2) had not undergone obesity surgery The Roux-limb is now advanced trough the mesocolic win- before.44 procedures were done laparoscopically and 30 with dow (retrocolic) near the transected stomach when is fixed with Hand-assisted laparosco pic technique. All patients had interrupted sutures. Following an enterotomy an anastomosis obtained enoxaparin 20 mg daily or 500 ml dextran in a single between the gastric pouch and the Roux-limb is created by fir- dose as routine thrombosis prophylaxis during the hospital stay. ing a Endo GIA II.The enterotomy is closed using a continuous During Dec 1996-april 1998 116 of these patients were consec- suture. utively investigated with Duplex scanning pre and postoperatively to investigate the presence of deep venous thrombosis or P70.QUALITY OF LIFE IS IMPROVING AFTER LAP-BAND deep venous insufficiency. GASTRIC BANDING FOR MORBID OBESITY. Results:During this five year period with 285 RYGBP proce- Saida Bedda, Jean-Marc Chevallier, Franck Zinzindohoue, dures there were 2 (0.7%) patients with symptomatic DVT diag- Richard Douard, Jean-Louis Berta, Jean-Jacques Altman, Paul-

Obesity Surgery,11, 2001 445 Crete Abstracts

Henri Cugnenc. Departments of Surgery and Nutrition.Hô pital dell’Università degli Studi di Milano - Istituto Clinico Européen Georges Pompidou, 20-40 rue Leblanc 75908 PARIS Sant’Ambrogio (Direttore:Prof. S.B.Doldi) ;Centro per la cedex 15, France Farcomacoterapia delle Malattie Nutrizionali e Metaboliche “E. Background:Improvement in quality of life is the principal aim Genovese e R. Klinger”, Milan, Italy of surgery against morbid obesity.Excess weight loss (E.W.L.) Background:Since 1993 we have operated on 325 morbidly is a quantitative purpose, but clearance of comorbidities and obese patients with adjustable gastric banding according to improvement of quality of life are at least as important.The Kuzmak :43 with open technique, 262 with laparoscopic tech- Bariatric Analysis and Reporting Outcome System method nique(Lap-band®). Rate of conversion to open laparotomy was (BAROS), introduced by Oria and Moorehead in 1997, was pro- 7,6% (20 patients).The patients were examined by a multidisci- posed to standardize the results of bariatric procedures.We plinary team.The indications and contraindications we have fol- used this method to evaluate our results on an experience of lowed were the same adopted in NIH conference (1991). four years. Methods:Our series includes: 325 patients (63 Male/ 262 Method:This system use a point scale to evaluate in one Female);mean age 37,5 y (18–67); preoperative mean weight page record three important fields:weight loss, improprement of Kg 118,8 ±24,7 (85-218);mean BMI 43 ±6,8 (35-71);mean fol- medical conditions and quality of life after surgery .Coloured low-up is 6 years.The patients in open surgery were:24 in pre- illustrations are used to evaluate five areas:self esteem, physi- laparoscopic era; 12 conversions from jejuno-ileal bypass; 1 cal activity, social life, working conditions and sexuel satisfac- conversion from bilio-intestinal bypass;3 conversions from bilio- tion.Complications and re-operations also result in substraction pancreatic diversion;3 from silastic ring vertical gastroplasty. of points.The final scoring table classifies five groups depend- Results:The mean weight loss after two years is 30.2% of the ing on the total points :failure 1point or less, fair > 1 to 3 points, initial mean weight, with the reduction of the excess weight of good >3 to 5 points, very good >5 to 7 points and excellent 62,5% and in BMI of 29,5%.The main early complications were: result > 7 to 9 points.From april 1997 to january 2000, among gastric perforation (2,4%), half repaired in laparoscopy;hemor- 300 patients 140 , who underwent lap-band surgery, were eval- rhage from short vessels (1 patient) repaired in laparotomy; uated with BAROS, 128 women (91%) and 12 men (9%).The band slippage(2 patients), one treated by removing the band mean age was 41 yrs (22-68), the mean body weight was 117 and the other by replacement in laparoscopy.All these compli- Kg (85-195) and the mean body mass index (BMI) was 43 cations occurred at the beginning of our experience.The major Kg/m2 (31-61).The mean follow-up was 14 months (6-31). late complications were: migration of the adjustable gastric Results:BMI decreased from 43 Kg/m2 to 38 after 6 months (n=48), to 34 after 12 months (n=38), to 32 after 18 months banding (0,9%);dilatation of the proximal gastric pouch (9,2%), (n=32) and to 31 after 24 months (n=11).EWL increased to 41% 50% treated by medical care and the other by surgery (removal at 6 months, 44% at 12 months, 54% at 18 months and 24 or replacement of the gastric banding or conversion in bilio- months.BAROS score was 3.64 at 6 months, 3.79 at 12 intestinal bypass).Those medically treated were early identified months, 4.38 at 18 months and 5.20 at 24 months.According to by a water soluble upper gastric contrast study :our more than BAROS, the global failure rate was 6%(n=8), fair results 18% 2000 contrast studies showed that the gastric pouch dilatation (n=25), good results in 49% (n=68), very good results in 24% can be facilitated by an oesophago-banding angle included (n=34) and excellent results in 3% (n=5).The BAROS score and between 210 and 150° . Other minor late complications were the quality of life (auto-evaluation) were correelated significantly leak or infection of the device (2,4%). to the excess weight loss (p> 0,01). Conclusion:The adjustable gastric banding and specifically Conclusion:The quality of life evaluated by the BAROS sys- the Lap-band is the first choice surgical treatment in the major- tem after lap-band surgery was good, very good or excellent in ity of the morbidly obese patients.Lap-band is effective, adapt- 107 / 140 of cases (76%). The BAROS and quality of life able and economically advantageous. These good results are improved with time significantly. possible only in bariatric specialized centers and following this suggestions:virtual proximal gastric pouch (15 ml);embedding P71.OUR BARIATRIC SURGERY EXPERIENCE WITH the banding with non absorbable stitches; diligent follow-up, ADJUSTABLE GASTRIC BANDING. above all to early recognize gastric pouch dilatation by x-ray Bressani Doldi Santo, Micheletto G., Perrini M., Lattuada E., studies;adherence of the patient to definitively mutation of the Zappa M.A., Fioravanti M. Cattedra di Chirurgia Generale alimentary habit.

446 Obesity Surgery,11, 2001