Abstracts from the XVII World Congress of ...

OBES SURG (2012) 22:1315–1419 DOI 10.1007/s11695-012-0713-1

ABSTRACTS

Abstracts from the XVII World Congress of International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), New Delhi 11–15 September, 2012 Published online: 15 August 2012 O001 Incidence of Marginal Ulcer After Laparoscopic Roux-en-Y Gastric Bypass and Roux Limb Course Presenter: Lara Ribeiro Parenti Co-author: Denis Chosidow Konstantinos Arapis Pierre Fournier Jean Pierre Marmuse Hopital Bichat Claude Bernard, France Background Marginal ulcer can be a serious complication after laparoscopic gastric bypass surgery. The aim of this study was to determine the rate of anastomotic ulcer in a large cohort of patients and to identify patient or technique factors predisposing to such complication. Methods Over a near 10-year period, 1142 patients underwent laparoscopic gastric bypass surgery. The antecolic and the retrocolic technique wasused in 572 and 570 consecutive patients respectively. All procedures were performed using a circular stapled gastrojejunostomy. Results Patients were followed for 18 to 99 months (mean 48.8 months). During follow-up, 46 patients developed a marginal ulcer (4 %), 32 in the antecolic group (5.6 %) and 14 in the retrocolic group (2.5 %). Nineteen patients (3.3 %) in the antecolic group and 8 patients in the retrocolic group (1.4 %) developed early marginal ulcer (i.e. within 3 months after surgery). The mean time to onset of anastomotic ulcer symptoms after surgery was 11 months (range 0.25 -72). Forty-four patients were submitted to medical treatment and 34 patients (77.3 %) had complete resolution of their symptoms. On multivariate analysis, the antecolic technique was identified as a risk factor of marginal ulcer (p 00.007) and early marginal ulcer (p 00.033). Conclusion A significant lower incidence of marginal ulcer was observed in the retrocolic group. The antecolic technique is a risk factor for appearance of marginal ulcer. Keywords: stomal ulcer, marginal ulcer, gastric bypass, complications, bariatric surgery. O002 Comparative Single Centre Analysis of Outcome Following Different Modalities of Bariatric Surgery for Obesity Presenter: Vittal Rao Co-author: Rupa Sarkar, Mark Peter, Aravind Suppiah, Peter Sedman, Prashant Jain Castel Hill Hospital, Cottingham, Hull, United Kingdom Introduction Bariatric surgery is associated with long-term weight loss. We report a large single centre experience of different modalities of bariatric surgery over a 12 year period. Methods A retrospective database review of patients who underwent bariatric surgery between 1998 – 2009 was undertaken. Type of surgery and outcome (percentage excess body weight loss:%EBWL) was analysed. Statsitical analysis was performed using likelihood ratio chi square test.

Results 951 patients underwent gastric band (LAGB; n 0211), gastric bypass (LRYGB; n0700) and sleeve gastrectomy (LSG; n040) laparoscopically. Patient groups were comparable for demographic profile. Pre-op mean BMI (LAGB:49; LRYGB:48; LSG:58) and mean excess body weight (EBW in Kg; LAGB: 73; LRYGB:72; LSG:101) was recorded. Mean %EBWL at mean follow up (LAGB: 40 % at 47 months; LRYGB: 60 % at 23 months; LSG: 47 % at 19 months) was analysed. Older people had significantly lower %EBWL at all times (p00.034). People with higher EBW had significantly lower predicted % EBWL at 12 months but the gap narrowed with time (p50 %), with low postoperative morbidity. Further information is required to compare diabetic resolution and long-term weight loss. O011 Early Results of Laparoscopic Greater Curvature Gastric Plication Presenter: Ludo Van Krunckelsven Co-authors: Jan Yperman Hospital Jan Yperman Hospital, Belgium Background We evaluated safety and efficiency of gastric plication in a series of 100 patients(35 % male,65 % female) with mean age 32 (15-65)y ,mean BMI 35 (30-42) and mean IEW 65 (40-110)%. Methods A laparoscopic gastric plication was performed with greater curvature liberation from 7 cm prepyloric up to the cardia and two layer plication ( interrupted 2/0 silk, running suture 2/0 prolene) calibrated on a 36 F gastric tube. We include cholecystectomy and for reflux disease hiatal closure was performed. Results Mean operating time was 60 minutes without blood loss or conversion.Mean hospital stay was 48 hours.There were no pulmonary,urinary, wound or thromboembolic complications,no perioperative mortality. 1 relaparoscopy was needed for closure of a small perforation near the cardia (ripped out suture after excessive drinking on postop day 1). In 3 patients a gastric outlet problem due to swelling was treated conservatively with resolution within 3 days. Follow up of weight loss in this series now ranges from 3 to 9 months: mean %loss of the IEW was 40 % at 2 months,70 % at 4 months,88 % at 6 months and 92 % at 9 months.Up to now no long term side effects or gastric ulcerations were noted,no malnutrition or vitaminary deficiency. Conclusion In this series gastric plication appears to be a very safe and effective weight loss operation. Longer follow up and larger series are of course necessary.Currently we are also expanding our indications to higher BMI ranges and reoperations (resleeve,failed gastric band).

1318 O012 Laparoscopic Duodenojejunal Bypass with Sleeve Gastrectomy – A Novel Procedure for Resolution of Metabolic Syndrome in Patients with BMI 7.5.Laparoscopic Duodenojejunal bypass was done in a retro colic fashion, anastomosis being done by end-end with a 60 F Sleeve, 75 cm for the biliopancreatic limb and 125 cm for Roux limb. Results A total of 18 patients (10 women, 8men) were retrospectively studied. The mean age was 40.5 yrs.The mean pre-operative BMI, (Fasting Blood Glucose) FBG and HbA1C was29.5,200.8 mg/dl and 8.3 %.The postoperative BMI,FBG and HbA1C at the end of 6mts and 1 year was 26.4,113.2,6.6 %,and 24.6,108.4,6.3 % respectively. 16out of 18 patients with diabetes had complete remission.5 out of 7 patients with hypertension had complete remission.9 patients had dyslipidemias and all had complete normalization of all parameters Conclusion Laparoscopic Duodenojejunal bypass with Sleeve, which combines the principles of sleeve gastrectomy and foregut hypothesis, is an effective procedure for resolution of diabetes and other co-morbidities in lower BMI population. With its additional advantages of presence of a remnant stomach that’s amenable to endoscopic surveillance the procedure is best suited for a country like India. O013 Single-incision Laparoscopic Gastric Bypass vs Conventional Technique: A Retrospective Analysis Presenter: Praveen Raj Co-authors: P Senthilnathan,B.Vijay,Parimala,Roja Ramani,Palanivelu C Gem Obesity&Diabetes Surgery Centre,Gem Hospital&Research Centre, India (for oral) Background Laparoscopic Roux-en-Y gastric bypass (LRYGB) is gold standard for bariatric surgery, but the procedure requires five to seven incisions for placement of multiple trocars and thus may produce less-than-ideal cosmetic results. Recently, the concept single-incision laparoscopic surgery has been used for bariatric procedures, and this surgery may be the next step in minimally invasive surgery. Methods All patients who underwent Roux en Y gastric bypass between May 2010-May 2011 were retrospectively studied from the hospital database Results It included 16 patients who underwent the Single incision technique (Group I) and 67 patients who underwent the conventional technique (Group II).The mean age for Group I patients was 32.5 and that for Group II was 44.8 yrs.The mean operating times were 88 min in Group I and 131 min in Group II.There was no difference in the duration of hospital stay,post operative pain score or analgesic usage in both the group of patients. The mean weight loss was also similar. Conclusion Single Incision laparoscopic surgeries are gaining popularity around the world and the same applies to gastric bypass as well. Based on the above results it can be concluded that except for the cosmetic advantage, there is no added benefit in terms of the post operative outcome variables.The added technical difficulty needs no mention.

OBES SURG (2012) 22:1315–1419 An analysis of the latest results of laparoscopic greater curvature plication. laparoscopic plicated gastric band and laparoscopic ileal interposition will be discussed. Advances in laparoscopic gastric pacing technology through the Introduction of the Abiliti pacing system will be described in detail. A summary of the results of percutaneous placed extra-gastric implants to induce early satiety, currently being trialled in Australia, will be made. An overview of advances in endoluminal suturing technology by way of the Apollo Overstitch in the treatment of weight regain post-gastric bypass by way of stoma size reduction, closure of gastro-gastric fistulae and treatment of sleeve leaks at the Angle of His will be made. Novel endoluminal implants such as the Transpyloric Shuttle and endosphere speed bumps will be described as well as an update on Endobarrier technology, by way of the Gastrointestinal Liner and Valentx systems. The concept of the ‘smart band’ with an in-built intra-band pressure stabiliser will be introduced and its’ rationale for clinical use. O015 Effect of Laparoscopic Roux-en-Y Gastric Bypass on Metabolic Syndrome and glp-1 Hormone in a Group of Egyptian Patients Presenter: Alaa Abbass Moustafa* Co-authors: Reda AbdelTawab*, Mohamed ElSayed*, Islam Hossamel Din*, Essam Abd El Galil***, Islam Hossam *Randa Reda,** Nesrine Ali,**Rania el Kabrity** General Surgery Department* and Immunology & Clniical Pathology Department**Surgery Unit Ahmed Maher Teaching Hospital***, Faculty of Medicine – Ain Shams University, Egypt Introduction An enlarged incretin response after Roux-en-Y gastric bypass (RYGBP) has been proposed to promote profound weight loss and obesityrelated comorbid condition same lioration especially type 2 diabetes mellitus (T2DM). This aimed to prove that a truemetabolic surgery should be able to resolve one or more of the metabolic syndrome parameters independently of the body weight. Material & Methods The study included 30 patients with BMI of 30-36 Kg/m2. The study intended to evaluate the effect of laparoscopic Roux-en-Y gastric bypass as a metabolic surgery on metabolic syndrome parameters and on fasting serum GLP-1 after one year in metabolic syndrome patients. Results The selected group of patients had different degrees of glucose tolerance: normal glucose tolerance (NGT, n09), impaired glucose tolerance (IGT, n09), and type 2 diabetes(n012). This study was done to determine the changes of GLP-1, BMI, insulin resistance before and 1 year after Lonroth’s laparoscopic RYGBP. There was a high significant increase in serum GLP-1, postoperatively from 63.67(31) to123(32.7) ng/ml, in all these three groups, postoperatively .There was high significant decrease in fasting glucose from 145.3(66.8) to 99.2 (13.9) mg/dl, and significant decrease in fasting insulin from16.1(5.5)to11.3(4.4) Iu/liter, in all these three groups ,postoperatively, along with a high significant decrease in HOMA-IR from 5.45 (+\-2.35) to 2.78 (+\-1.1). Discussion & Conclusion Metabolic Syndrome improved significantly postoperatively, including dyslipidemia, hypertension, and obesity. These findings indicate that RYGBP is associated with alterationsin glucose kinetics and glucoregulatory hormone secretion, leading to improvement of type IIDM. O016 Adjustable Gastric Banding Improves Obesity and Weight-Loss Quality of Life (owlqol) Measures Over 3 Years: Interim Results: of the Apex Study Presenter: Ted Okerson MD FACP Co-authors: Jaime Ponce MD, Helmuth Billy MD, Adam Smith DO, Trace Curry MD, Christopher Cornell PhD, Ted Okerson MD FACP and the APEX study group

O014 Latest Developments in Metabolic and Bariatric Surgery

Allergan, United States of America

Presenter: HA Khwaja Co-authors: SM Javed, CJ Magee, DD Kerrigan

Introduction Laparoscopic Adjustable Gastric Banding has been established as a safe, effective treatment to reduce weight in obese patients. This summarizes the 3-year prospective outcomes of the Obesity and Weight-Loss Quality of Life (OWLQOL) instrument after surgical placement of the LAPBAND AP® (LBAP) device. Methods The APEX trial is an ongoing 5-year open-label study to assess the progressive weight reduction, change in comorbidities and OWLQOL results

Gravitas, United Kingdom The evolution of metabolic/bariatric surgery has proceeded at a phenomenal pace over the last 10 years.

OBES SURG (2012) 22:1315–1419 after implantation of the LBAP (NCT00501085). The well-validated OWLQOL was prospectively provided pre-implantation and at 6 month intervals post-operatively. This represents an interim analysis of the 159 evaluable subjects (159/359) who have exited or completed the 30-month postoperative visit. Results Significant improvements in all questions of the OWLQQOL were observed within 6 months after implantation and continued to improve over 3 years. Mean change in score from baseline was -2.2 (range -0.9 (Q16 fear of weight regain) to -3 (Q7 ability to do what I want)). Total score improved from 70.4 at baseline to 33.3 at 3 years, (mean total improvement of 53 % from baseline (range 24 % (Q16) to 65 % (Q7)). These improvements correlated with the mean 52 % excess weight loss (%EWL) and with remission /improvement of many comorbidities of obesity: type 2 diabetes (96 %), hypertension (91 %), hyperlipidemia (77 %), GERD (91 %), sleep apnea (86 %), arthritis (75 %) and depression (93 %). Conclusion Weight loss facilitated by LBAP placement offers meaningful improvement in all 17 OWLQOL measures, and correlates with significant %EWL and comorbidity changes. Durability of these improvements will be followed and reported over 5 years. O017 Biliopancreatic Diversion/Duodenal Switch – Revisional Cases Presenter: Yury Yashkov Institution: Center of Endosurgery and Lithotripsy, Moscow, Russia Background Every bariatric operation may lead to the necessity of revisions in the late postoperative period. Malabsorptive procedures may be indicated in case of poor result after simple restrictions, but may themselves demand conversions or revisions by different reasons. The aim of this study is to evaluate the results of Biliopancreatic Diversion/Duodenal Switch (BPD/DS) as a revisional operation and to evaluate the outcomes of revisional surgery after BPD/DS. Methods Series of 360 BPD/DS done since 2003 is studied with a special attention to: 1) BPD/DS done as a revisional surgery, 2) revisions done after BPD/DS. Operative outcomes and late results are presented. Results 16 of 360 patients (4,4 %) had DS as a revisional procedure after: vertical banded gastroplasty (VBG) - 9, gastric banding - 4, sleeve gastrectomy (SG) -2, horizontal gastroplasty-1. 7,7 % patients underwent revisional operations after BPD/DS: bowel shortening -15 (4,2 %), re-resections or sleeve-plication – 5 (1,4 %), lengthening of bowels for protein malnutrition 8 (2,2 %), gastric banding-1 (0,28 %). There was no mortality. Revisions from VBG to BPD/DS were technically more demanding operations with potential risk of complications. Additional gastric restrictions provided better weight loss than bowel shortening alone in case of insufficient weight loss after BPD/DS. Conclusions BPD/DS is a very effective solution after failed restrictive operations. Further revision of insufficient weight loss after BPD/DS should include not only bowel shortening but also further gastric restriction. O018 Laparoscopic Adjustable Gastric Banded Plication: 2 Year Results and Evolution of Procedure Presenter: Dr. Satish Pattanshetti Co-authors: Dr. C.K Huang, Dr. Rajat Goel E-Da Hospital, Kaohsiung, Taiwan Background Laparoscopic adjustable gastric banded plication (LAGBP) is a new restrictive bariatric procedure combining adjustable banding and greater curvature plication of the stomach. This study aimed to report the evolution of this surgical technique and analyze the surgical results. Methods Eighty patients receiving LAGBP were enrolled in this study. The band-first technique was used for 50 patients from May 2009 to June 2011 and was then changed to the plication-first technique from July 2011 to October 2011. Patients’ demographics and pre- and postoperative data, including complications and weight loss, were collected and analyzed. Results Eighty patients (26 men and 54 women) with a mean age of 30.75± 8.68 years and a mean BMI of 38.05±4.73 kg/m2 were evaluated with a mean follow-up for 10.52 (1–24) months. Average operation and hospitalization times were 92.85±35.86 minutes and 1.73±1.04 days, respectively, when there were no intraoperative complications or surgical mortality. There were

1319 4 (8 %) postoperative complications with the band-first technique and 1 (3 %) with the plication-first technique. Mean percentage excess weight loss at 3, 6, 12, 18, and 24 months was 34.73±10.42, 42.59±13.67, 56.38±19.89, 57.59± 19.88, and 65.84±17.36, respectively. Band adjustment frequency was 2.44± 2.21 times in 2 years. Conclusion LAGBP is a new bariatric procedure with few complications and superior weight loss at the end of 2 years. We suggest that the plication-first technique be standardized to decrease postoperative complications. Long-term follow-up is necessary for standalone acceptance of this bariatric procedure. O019 Bariatric Evaluation and Surgical Follow Up: the Need to Incorporate Additional Mental Health Components Presenter: Connie Stapleton, Ph.D. An exemplary pre-surgical bariatric evaluation would be a comprehensive, multidisciplinary effort requiring consensus by all disciplines on the readiness of each patient for WLS. Of equal importance, is the need for the evaluation to point toward specific multi-disciplinary post-operative follow-up. The NIH Consensus Panel recommended careful selection of surgical candidates by a multidisciplinary team with access to psychiatric expertise. (NIH conference. Ann Intern Med1991). In 2005, a panel concluded that psychiatric evaluation was not needed routinely but should be available if indicated (Buchwald H. J Am Coll Surg 2005).“Although a comprehensive presurgical evaluation provides an opportunity to identify the small number of patients for whom surgery is contraindicated, for most individuals careful presurgicalevaluation should serve a planning and education function rather than a gatekeeping function.”(Kalarchian MA, Marcus MD. Cogn Behav Pract 2003)“The consultation provides an opportunity to review motivations for and expectations of surgery and to provide education. Individuals with psychiatric problems may benefit from treatment prior to surgery and from establishment of a plan for postsurgical monitoring and intervention.”(Marcus, MD, Kalarchain, MA, & Courcoulas, AP. Am J Psychiatry 2009; 166:285-291) “Postsurgical monitoring and intervention”… those are the key words. The pre-surgicalevaluation is a place to start helping patients prepare for the issues they will need toaddress throughout the WLS process, but more importantly, for a good deal of time following the actual surgery. A specific aftercare plan needs to be established at the time of a multidisciplinary team evaluation. O020 redicting the Glycemic Response to Gastric Bypass Surgery in Patients with type 2 Diabetes Presenter: John B. Dixon (MBBS PhD FRACGP)1 Co-authors: Lee-Ming Chuang (MD)2,3, Keong Chong (MD)4, Shu-Chun Chen (RN)5, Gavin Lambert (PhD)1, Nora Straznicky (PhD)1, Wei-Jei Lee (MD PhD)5. Baker IDI Heart & Diabetes Institute1, Melbourne, Victoria, Australia Objective To find clinically meaningful preoperative predictors of diabetes remission, and inadequate glycemic control or improvement following gastric bypass surgery. Predicting the improvement in glycemic control in those with type 2 diabetes following bariatric surgery may help in patient selection and counseling. Research design, Methods Preoperative details of 154 ethnic Chinese subjects with type 2 diabetes were examined for their influence on glycemic outcomes at 1-year. Remission was defined as HbA1c 6 %. Analysis involved binary logistic regression to identify predictors and receiver operator characteristics to determine clinically useful cut-off values. Results Remission was achieved in 107 (69.5 %) patients at 12 months. Diabetes duration of 35 kg/m2 and fasting Cpeptide concentration >2.9 ng/ml provided three independent preoperative predictors and three clinically useful cut-points. A combination of 2 or 3 of these predictors allows a sensitivity of 82 % and specificity of 87 % for remission. Duration of diabetes (with different cut-points) and C-peptide also predicted those not achieving HBa1c 7 % and a fall in HbA1c of