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Background: The Magenstrasse and Mill gastroplasty (M&M) is a gastric restrictive procedure without band or stomach resection. Short-term evaluation of the laparoscopic procedure showed low morbidity and satisfactory results on weight loss. Evidence of the validity of the technique in the longer term is scarce., Methods: Data from patients who underwent M&M procedure from May 2012 to September 2015 were retrospectively reviewed. Preoperative clinical characteristics and data up to 4 years after operation were analyzed., Results: A total of 132 patients were included in this study with a mean age of 46 ± 13.4 years. The mean body mass index (BMI) at the time of procedure was 43 ± 4.5 kg/m 2 . Mean percentage of excess weight loss (%EWL) was 67, 67, 58, and 57% at 1, 2, 3, and 4 years, respectively. The remission rate for diabetes was 36%. About half of the insulin-dependent patients could stop their insulin treatment. Hypertension was resolved in 33.8% of the patients after 4 years. Incidence of vitamin and mineral deficiency was low throughout the study period, less than or equal to 3% for vitamin B12 and 1% for ferritin. Incidence of gastroesophageal reflux did not exceed 15% during the study. Over 75% of the patients reported a good or very good quality of life following the surgery., Conclusion: These results confirm the validity of M&M as a bariatric procedure. The low incidence of vitamin deficiencies and gastroesophageal reflux might be the important asset of M&M over other existing techniques.

Objective: This study was undertaken to examine the factors contributing to laparoscopic adjustable gastric band (LAGB) removals among adults > 18 years of age. We hypothesized that female patients with multiple comorbidities would have increased removals., Design: This retrospective exploratory study uses internal records and standard statistical methods of analysis., Results: Eighty-five bands were removed (11.8% males, 88.2% females). The average BMI was 40.7 (n = 83). 2.4% of patients had removals between 0 and 12 months, 18.8% between 39 and 51 months, and 35.3% between 39 and 64 months. 8.2% of treatment times were unknown. The average treatment time was 67.9 months. 48.2% of patients had ≥ 2 comorbidities, GERD (44.2%) being the most frequent. 49.4% of patients reported dysphagia as the reason for band removal. 22.4% of removals were associated with band failures, none with port complications. The reason for band removal was unknown in 21.2% of patients. 67.1%, 32.9%, and 23.5% attended 30-, 60-, and 90-day follow-up appointments, respectively. Weight post-band removal surgery at 30, 60, and 90 days was noted to be - 0.4%., 0.9%, and 0.4%, respectively., Conclusion: This study supports current literature suggesting LAGB may not be an effective long-term surgical intervention for obesity. Patients with > 2 comorbidities had increased rates of removal. Dysphagia was noted to be the primary reason cited for LAGB removal. Postoperative follow-up was found to be a significant challenge for LAGB removal patients. Further study is warranted to explore if these poor follow-up rates should be considered when risk stratifying LAGB patients for revisional surgery.

Objective: Hepatic insulin clearance is a significant regulator of glucose homestasis. We hypothesized that the improvement in insulin clearance rates (ICRs) under fasting conditions and in response to oral and intravenous (IV) glucose would improve similarly after Roux-en-Y gastric bypass (RYGB) and adjustable gastric banding (AGB) as a function of weight loss; the difference in ICR after oral and IV glucose stimulation will be enhanced after RYGB compared with AGB, an effect mediated by glucagon-like peptide 1 (GLP-1)., Research Design and Methods: In study 1, the ICR was calculated under fasting condition (F-ICR), after oral glucose (O-ICR), and after an isoglycemic IV glucose clamp (IV-ICR) in individuals from an established cohort with type 2 diabetes mellitus (T2DM) before, after 10% matched weight loss, and 1 year after either RYGB ( n = 22) or AGB ( n = 12). In study 2, O-ICR was studied in a separate cohort of individuals with T2DM ( n = 22), before and 3 months after RYGB, with and without exendin(9-39) infusion., Results: In study 1, age, BMI, T2DM duration and control, and ICR did not differ between RYGB and AGB preintervention. Weight loss at 1 year was two times greater after RYGB than after AGB (31.6 ± 5.9% vs. 16.6 ± 9.8%; P < 0.05). RYGB and AGB both significantly increased F-ICR, O-ICR, and IV-ICR at 1 year. ICR was inversely associated with insulinemia. The difference between IV-ICR and O-ICR was significantly greater after RYGB versus AGB. GLP-1 antagonism with exendin(9-39) led to an increase in O-ICR in subjects post-RYGB., Conclusions: Weight loss increased ICR, an effect more pronounced after RYGB compared with AGB. Our data support a potential role for endogenous GLP-1 in the control of postprandial ICR after RYGB., (© 2018 by the American Diabetes Association.)

Background: The effects of laparoscopic adjustable gastric band (LAGB) placement on upper gastrointestinal tract function in obese adolescents are unknown. Therefore, our aim was to determine the short-term effects of LAGB on esophageal motility, gastroesophageal reflux, gastric emptying, appetite-regulatory hormones, and perceptions of post-prandial hunger and fullness., Methods: This study was part of a prospective cohort study (March 2009-December 2015) in one tertiary referral hospital. The study included obese adolescents (14-18 years) with a body mass index (BMI) > 40 (or ≥ 35 with comorbidities). Gastric emptying was assessed by 13 C-octanoic acid breath test, pharyngeal, and esophageal motor function by high-resolution manometry with impedance (HRIM), and appetite and other perceptions using 100-mm visual analogue scales. Dysphagia symptoms were scored using a Dakkak questionnaire. Data were compared pre- and post-LAGB placement and at a 6-month follow-up., Results: Based upon analysis of 15 adolescents, at the 6-month follow-up, LAGB placement: (i) led to a significant reduction in weight and BMI; (ii) increased fullness and decreased hunger post-meal; (iii) increased symptoms of dysphagia after solid food; and, despite these effects, (iv) caused little or no changes to appetite hormones, while (v) effects on gastric emptying, esophageal motility, esophageal bolus transport, and esophageal emptying were not significant., Conclusion: In adolescents, LAGB improved BMI and altered the sensitivity to nutrients without significant effects on upper gastrointestinal tract physiology at the 6-month follow-up.

Background: Laparoscopic greater curvature plication (LGCP) is an innovative restrictive technique designed to reduce gastric volume by plication at the region of greater curvature. The long-term efficacy, safety, and the metabolic effects of this procedure are the subject of this study., Methods: One hundred twenty-seven patients were enrolled; 84 underwent laparoscopic sleeve gastrectomy (LSG) and 43, LGCP. LSG and LGCP were then compared during long-term follow-ups in terms of glycemic control, hormone and lipid secretion, and changes in body composition. Measured parameters included serum glucose, triglycerides, high- and low-density lipoprotein cholesterol, testosterone, estradiol, leptin, adiponectin, ghrelin, fatmass, and lean body mass., Results: Significant weight-loss and a reduced body composition resulted from either procedure vs. baseline (i.e., pre-surgery), with levels of fasting glucose and glycated hemoglobin also showing statistically significant reductions (at 3 and 18 months for either surgery). Intergroup comparisons for glycemic parameters yielded no statistically significant differences. However, a dramatic reduction in ghrelin was detected following LSG, falling from pre-surgery levels of 140.7 to 69.6 ng/L by 6 months (P < 0.001). Subsequently, ghrelin levels increased, reaching 107.8 ng/L by month 12. Conversely, after LGCP, a statistically significant increase in ghrelin was seen, rising from 130.0 ng/L before surgery to 169.0 ng/L by month 12, followed by a slow decline., Conclusions: Good metabolic outcomes were obtained following LGCP, which might be mediated via altered glucose metabolism and GI hormones. Nevertheless, this method is less effective than LSG, possibly due to its preservation of the entire stomach, including secretory regions.

Background: A failed laparoscopic sleeve gastrectomy (LSG) presents a challenging problem for bariatric surgeons. The aim of this study was to evaluate the indications, treatment strategies, and surgical outcomes of patients who underwent a revisional surgery after a failed LSG., Methods: This retrospective study included the outcomes of 32 patients who required a revisional surgery from a series of 500 primary LSGs. The patients' demographic data, indications for revisional surgery, perioperative complications, and postoperative outcomes were recorded., Results: A total of 500 patients underwent primary LSGs during the study period, and 32 of these patients were subjected to revisional bariatric surgery after a failed LSG. Weight regain, poor weight loss, and gastroesophageal reflux disease (GERD) were the most common causes of revision. A revisional LSG (r-LSG) was performed in 23 patients, while 9 patients received a revisional laparoscopic Roux-en-Y gastric bypass (r-LRYGB). There were complete sleeve pouch dilations in 10 patients. A residual fundus and antrum dilation was detected in 5 and 8 patients, respectively. The r-LRYGB procedure was performed for GERD-related symptoms in 6 patients and 3 other patients underwent r-LRYGB due to the intake of high-caloric foods. The mean operative time, length of hospital stay, and complication rates of revisional surgeries were significantly higher than the total cohort., Conclusions: Although r-LSG and r-LRYGB seem to be safe and effective treatment options after a failed LSG, revisional procedures were associated with an increased complication rate. Attention to technical details of the primary LSG may reduce the revision requirements.

Background: Laparoscopic adjustable gastric banding (LAGB) remains one of the most performed bariatric procedures worldwide, but a few long-term studies have been reported often with limited data at time of longest follow-up. We review our 18-year LAGB experience with special regard to weight loss failure and long-term complications leading to band removal., Methods: We performed 897 LAGB procedures from April 1996 to December 2007: 376 using the perigastric dissection and 521 using the pars flaccida dissection. We performed a retrospective analysis of the data of this consecutive series. Failure was defined as band removal with or without conversion to another procedure or excess weight loss (EWL%) <25 %., Results: There were 120 men and 770 women. Mean age was 39.5 years, and mean BMI was 45.6 kg/m 2 . Mean follow-up was 14.6 years (range 101-228 months) with 90 % follow-up beyond 10 years. Ten (1.1 %) had early complications and 504 (56 %) late complications. Overall, 374 (41.6 %) bands were explanted for complications, weight regain, or intolerance. Mean 15-year EWL% in patients with band in place was 41.73 %. Over time, band failure rate increases from 18.4 % at 2 years to 43 % at 10 years and more than 70 % beyond 15 years., Conclusions: Despite good initial results, late complications, weight regain, and intolerance lead to band removal in nearly half of the patients over time. However, given that there is no good information on alternative procedures in the long term and considering its reversibility and safety still has a place in the treatment of morbid obesity for informed and motivated patients.

Background: Extreme obesity increases morbi-mortality in bariatric surgery. We previously showed that significant weight loss can be obtained within 3 months in super-super obese patients (BMI > 60 kg/m(2)) with an intragastric balloon (IGB). Here, we explored the potential benefit of preoperative IGB on the outcome of laparoscopic gastric bypass (LGBP) in super-super obese patients., Methods: In this case-control study, we compared the records of 60 consecutive super-super obese patients (66.5 ± 3.4 kg/m(2)) submitted to a LGBP between 2004 and 2009, with preoperative IGB (n = 23, cases) or without (n = 37, controls). We analyzed the clinical outcome of surgery and a composite end point of significant adverse events defined as the presence of at least one of the following conditions: conversion to laparotomy, intensive care unit stay for more than 2 days, and overall hospital stay superior to 2 weeks., Results: All baseline clinical and biological characteristics were homogenous between both groups. IGB was maintained during 155 ± 62 days and induced a loss of 5.5 ± 1.3 kg/m(2) (11.2 ± 3.2% of excess body mass index) at the time of LGBP, associated with a decrease in systolic blood pressure and gamma-glutamyl transpeptidase level (p < 0.05 vs. baseline). Operative time was lower in the IGB group (146 ± 47 vs. 201 ± 81 min in controls; p < 0.01). Significant adverse events occurred less frequently after LGBP in the IGB group (2 vs. 13 in controls; p < 0.05). All patients were alive at 1 year and overall weight loss was similar in both groups (52.4 ± 17.3 vs. 50.3 ± 12.7 percent of excess BMI loss in controls; NS)., Conclusions: IGB prior to LGBP in super-super obese patients significantly reduced excess BMI. It was associated with a shorter operative time and a lower overall risk of significant adverse outcomes.

The goal of this study was to understand the mechanisms of greater weight loss by gastric bypass (GBP) compared to gastric banding (GB) surgery. Obese weight- and age-matched subjects were studied before (T0), after a 12 kg weight loss (T1) by GBP (n = 11) or GB (n = 9), and at 1 year after surgery (T2). peptide YY(3-36) (PYY(3-36)), ghrelin, glucagon-like peptide-1 (GLP-1), leptin, and amylin were measured after an oral glucose challenge. At T1, glucose-stimulated GLP-1 and PYY levels increased significantly after GBP but not GB. Ghrelin levels did not change significantly after either surgery. In spite of equivalent weight loss, leptin and amylin decreased after GBP, but not after GB. At T2, weight loss was greater after GBP than GB (P = 0.003). GLP-1, PYY, and amylin levels did not significantly change from T1 to T2; leptin levels continued to decrease after GBP, but not after GB at T2. Surprisingly, ghrelin area under the curve (AUC) increased 1 year after GBP (P = 0.03). These data show that, at equivalent weight loss, favorable GLP-1 and PYY changes occur after GBP, but not GB, and could explain the difference in weight loss at 1 year. Mechanisms other than weight loss may explain changes of leptin and amylin after GBP.

Because of the increased incidence of obesity today, bariatric surgery is now considered to be an acceptable treatment modality. However, much of the information that exists in the media focuses on the procedure itself, not on the preoperative and postoperative issues that can be just as important to address. As a certified registered nurse practitioner who deals with these patients on a daily basis, and as a patient who has had both the vertical banded gastroplasty and the Roux-en-Y gastric bypass, I consider myself as having a better understanding of the entire process than most. Everyone who chooses bariatric surgery has his or her own motivating factors, whether it be to feel better, to get off his or her medications, or to better control or resolve his or her comorbid conditions; the list is endless. The most important factor is educating oneself and knowing all there is to know about whatever procedure is desired. Insurance companies are now requiring nutritional consults preoperatively that lay the foundation for bariatric patients postoperatively. It is imperative as a healthcare consumer to ask questions, attend classes and support groups, and follow the guidelines that the surgeon has established so as to be successful. I have been through it all and understand the process from beginning to end. I also have extraordinary compassion, sensitivity, and empathy for the bariatric patients, because of my previous experiences. People who have never had a weight problem cannot begin to understand the plight of those who do. I try to guide the patients and point them in the right direction; however, the decisions that they make are ultimately theirs.

Objective: To find out whether weight reduction induced by vertical banded gastroplasty (VBG) alters the energy expenditure in severely obese women during treadmill walking., Design: A prospective one year follow-up study, patients being their own controls., Setting: University hospital, Sweden., Subjects: A consecutive series of 11 women who had VBG., Main Outcome Measures: Indirect calorimetry, body mass index (BMI), preset and comfortable walking speeds, heart rate, perceived exertion, and quality of life., Results: 11 patients were evaluated. Mean BMI (kg/ml) decreased from 41 (range 36-46) before to 32 (range 25-37) 12 months postoperatively. The energy expenditure decreased significantly both at comfortable and preset walking speeds. The comfortable walking speed increased from 2.7 km x h(-1) (range 1.3-3.4) before operation to 3.8 (range 2.0-4.2) one year postoperatively (p = 0.003). All bodily variables in the SF-36 questionnaire showed improvement from 6 months onwards., Conclusion: Weight reduction in women reduces the energy expenditure during walking both at comfortable and preset speeds. The comfortable walking speed is increased. The improvements are reflected in the patients' own assessment.