Airam Sayarra

Background: The use of the laparoscopic sleeve gastrectomy (LSG), a restrictive operation, in different settings, is presented. Methods: 31 patients underwent LSG in the following groups: 1) 7 patients with very high BMI as a first stage of the duodenal switch (DS); 2) 7 morbidly obese patients with severe medical conditions; 3) 16 obese patients with lower BMI (35-43); and 4) 1 patient converted from a prior gastric banding. Results: 1 patient with BMI 74 died, a 3.2% mortality. The percentage of excess BMI loss (%EBMIL) in group 1 above was 63.1% from 4-27 months. The %EBMIL of the cirrhotics in group 2 was 76.0% (69-100%). The %EBMIL in group 3 patients was 68.5% (58.3-123%) at 3-27 months. The %EBMIL of the group 4 patient is 13% because she had previously lost almost all of her EBMI. Conclusion: LSG may become the ideal operation for staging in patients with BMI >55, for treating morbidly obese patients with severe medical conditions, as an excellent alternative to adjustable bands in lower BMI patients, or for conversion of gastric banding patients.

Background: Bariatric surgery is the only effective long-term treatment for morbid obesity. We compared long-term results of the vertical banded gastroplasty (VBG) and biliopancreatic diversion with duodenal switch (DS). Quality of life (QoL), weight loss (WL), and reoperation were evaluated. Methods: This is a retrospective study of 85 of 129 patients with VBG and 49 of 743 patients with DS, with follow-up >5 years. Mean preoperative BMI of the VBG patients was 48.8 kg/m2 and for the DS patients was 50.3 kg/m2. Results: Percent excess weight loss (%EWL) at 5 years for VBG patients was 56.4% and for DS patients 70.6% (P<0.0001). 8 VBG patients (9.4%) and 1 DS patient (2.0%) required re-operation due to failure of the technique. None of the VBG patients could eat a normal diet, while 80% of the DS had no restriction in the quality of their intake. Conclusions: At 60 months follow-up, only the DS patients fullfilled the ASBS requirements of %EWL >50 in over 75% of the patients.

Background: Laparoscopic sleeve gastrectomy (LSG) started as the restrictive part of the more complex laparoscopic duodenal switch (LDS) operation. There is no long-term experience with the isolated LSG. The main concern about the isolated LSG is the possibility of dilatation of the gastric pouch, long-term loss of restrictive function and weight regain. Laparoscopic re-sleeve gastrectomy (LRSG) has been used sparingly, but it also may become a possibility if more patients have the isolated LSG. Methods: 2 patients with BMI 58 and 65 respectively, underwent LSG as the first stage of the LDS. Later, when the patients regained some weight and their gastric pouch was found to be too large, the LRSG/DS was done. Results: The patient with BMI 58 had an initial drop to BMI 34 and regained weight to BMI 46, but after the LRSG/DS her BMI is 36 at 4 months. The BMI patient with BMI 65 had a drop to BMI 42, and after the LRSG/DS his BMI is 33 at 3 months later. Conclusion: LRSG may become necessary after gastric tube dilatation or insufficient original gastric volume reduction. LRSG is feasible, available and easy to perform when the resulting gastric pouch is too large or dilates after the original LSG.

Background: Nonalcoholic steatohepatitis (NASH) is the most common histological finding in morbidly obese patients undergoing liver biopsy. Biliopancreatic diversion has been widely used for the treatment of morbid obesity and hepatic steatosis, and very few cases of liver impairment as a complication of this operation have been reported. Methods: During the last 9 years, 470 morbidly obese patients were operated by means of a biliopancreatic diversion with duodenal switch ( BPD-DS), and 93 of them were performed laparoscopically. Results: 10 cases of clinical hepatic impairment occurred after the BPD-DS. The clinical course of these patients ranged from transient subclinical alterations of liver function tests to severe cases of jaundice and one death from liver failure. Conclusion: Randomized prospective studies with standardization of BPD-DS are needed, to know the real incidence of hepatic impairment and the proper treatment for this condition. Careful follow-up and correction of possible malnutrition should be addressed to avoid hepatic impairment and/or progression of liver disease.

Background: The duodenal switch (DS) is a variant of the biliopancreatic diversion (BPD), with a vertical subtotal gastrectomy and pylorus preservation. Methods: DS was used to treat morbid obesity in 125 patients, with mean BMI 50, with 65% of the patients super obese (SO). Patients have been followed for an intermediate period. Results: The percentage of excess weight loss (%EWL) was > 70% at 1 year, and reached 81.4% at 5 years when 97% of the patients had a %EWL > 50%. Comorbidities were cured or improved in all patients. Conclusion: DS was very effective for the treatment of the morbid obesity in the SO patients.

Background Duodenal switch (DS) is one of the most effective techniques for the treatment of morbid obesity and its co-morbidities, with mortality rate <1%, but with 9.4% morbidity rates (6.5% due to leaks). In our experience, leaks of the staple-line after sleeve gastrectomy (SG) are the most frequent sites of fistula formation and conservative treatment usually takes a long time.We present our experience in the treatment of gastric leaks with coated self-expandable stents (CSES). Methods 6 patients had gastric leaks at the gastroesophageal (GE) junction after SG or DS. One patient had a symptomatic gastro-bronchial fistula. Stents were placed by the interventional radiologist under fluoroscopic control and removed endoscopically. In one case, we used an uncoated Wallstent. In two patients, percutaneous microcoil embolization of the fistula was added. Results The patient treated with the Wallstent required a total gastrectomy 6 months after placement of the uncovered stent. In the other 5 patients, coated stents were successfully removed and the gastric leaks completely sealed. Conclusions CSES are proposed as an alternative therapeutic option for the management of GE junction leaks in bariatric surgery with good results in terms of morbidity and survival.

Background: Duodenal switch (DS) is one of the most effective techniques for the treatment of morbid obesity and its related co-morbidities, with mortality rates of <1%, but with 9.4% morbidity rates (6.5% due to leaks). We present our experience with 9 patients operated with a DS, who later underwent total gastrectomy (TG) for complications of the sleeve gastrectomy. Methods: From 1994 to March 2006, 846 patients underwent the DS. 9 patients (1%) underwent TG; 5 were due to gastric leak at the angle of His, 2 were related to leakage at the doudeno-ileal anastomosis (DIA), 1 was for stenosis of the gastric sleeve, and 1 for a gastroparesis. In 3 cases, the DS was the second bariatric operation. Full restoration of bowel anatomy was attempted in all patients. Results: TG has been the final solution for gastric complications of the DS in 9 (1%) of our 846 patients. In all cases, bowel anatomy has been restored, and there was no mortality. Postoperative courses have been difficult and hospital stays have been long in all patients (mean 4.5 months; range 1-10 months), with several episodes of re-do surgery after the TG. The actual BMI and %EBMIL are acceptable. Conclusions: TG successfully treated all 9 cases with life-threatening complications and difficult reinterventions after DS, without mortality. Restoration of bowel anatomy was done in all cases, with good final results.

Background: The use of the laparoscopic sleeve gastrectomy (LSG), a restrictive operation, in different settings, is presented. Methods: 31 patients underwent LSG in the following groups: 1) 7 patients with very high BMI as a first stage of the duodenal switch (DS); 2) 7 morbidly obese patients with severe medical conditions; 3) 16 obese patients with lower BMI (35-43); and 4) 1 patient converted from a prior gastric banding. Results: 1 patient with BMI 74 died, a 3.2% mortality. The percentage of excess BMI loss (%EBMIL) in group 1 above was 63.1% from 4-27 months. The %EBMIL of the cirrhotics in group 2 was 76.0% (69-100%). The %EBMIL in group 3 patients was 68.5% (58.3-123%) at 3-27 months. The %EBMIL of the group 4 patient is 13% because she had previously lost almost all of her EBMI. Conclusion: LSG may become the ideal operation for staging in patients with BMI >55, for treating morbidly obese patients with severe medical conditions, as an excellent alternative to adjustable bands in lower BMI patients, or for conversion of gastric banding patients.

Background: Bariatric surgery is the only effective long-term treatment for morbid obesity. We compared long-term results of the vertical banded gastroplasty (VBG) and biliopancreatic diversion with duodenal switch (DS). Quality of life (QoL), weight loss (WL), and reoperation were evaluated. Methods: This is a retrospective study of 85 of 129 patients with VBG and 49 of 743 patients with DS, with follow-up >5 years. Mean preoperative BMI of the VBG patients was 48.8 kg/m2 and for the DS patients was 50.3 kg/m2. Results: Percent excess weight loss (%EWL) at 5 years for VBG patients was 56.4% and for DS patients 70.6% (P<0.0001). 8 VBG patients (9.4%) and 1 DS patient (2.0%) required re-operation due to failure of the technique. None of the VBG patients could eat a normal diet, while 80% of the DS had no restriction in the quality of their intake. Conclusions: At 60 months follow-up, only the DS patients fullfilled the ASBS requirements of %EWL >50 in over 75% of the patients.

Background: Laparoscopic sleeve gastrectomy (LSG) started as the restrictive part of the more complex laparoscopic duodenal switch (LDS) operation. There is no long-term experience with the isolated LSG. The main concern about the isolated LSG is the possibility of dilatation of the gastric pouch, long-term loss of restrictive function and weight regain. Laparoscopic re-sleeve gastrectomy (LRSG) has been used sparingly, but it also may become a possibility if more patients have the isolated LSG. Methods: 2 patients with BMI 58 and 65 respectively, underwent LSG as the first stage of the LDS. Later, when the patients regained some weight and their gastric pouch was found to be too large, the LRSG/DS was done. Results: The patient with BMI 58 had an initial drop to BMI 34 and regained weight to BMI 46, but after the LRSG/DS her BMI is 36 at 4 months. The BMI patient with BMI 65 had a drop to BMI 42, and after the LRSG/DS his BMI is 33 at 3 months later. Conclusion: LRSG may become necessary after gastric tube dilatation or insufficient original gastric volume reduction. LRSG is feasible, available and easy to perform when the resulting gastric pouch is too large or dilates after the original LSG.

Background: Nonalcoholic steatohepatitis (NASH) is the most common histological finding in morbidly obese patients undergoing liver biopsy. Biliopancreatic diversion has been widely used for the treatment of morbid obesity and hepatic steatosis, and very few cases of liver impairment as a complication of this operation have been reported. Methods: During the last 9 years, 470 morbidly obese patients were operated by means of a biliopancreatic diversion with duodenal switch ( BPD-DS), and 93 of them were performed laparoscopically. Results: 10 cases of clinical hepatic impairment occurred after the BPD-DS. The clinical course of these patients ranged from transient subclinical alterations of liver function tests to severe cases of jaundice and one death from liver failure. Conclusion: Randomized prospective studies with standardization of BPD-DS are needed, to know the real incidence of hepatic impairment and the proper treatment for this condition. Careful follow-up and correction of possible malnutrition should be addressed to avoid hepatic impairment and/or progression of liver disease.

Background: The duodenal switch (DS) is a variant of the biliopancreatic diversion (BPD), with a vertical subtotal gastrectomy and pylorus preservation. Methods: DS was used to treat morbid obesity in 125 patients, with mean BMI 50, with 65% of the patients super obese (SO). Patients have been followed for an intermediate period. Results: The percentage of excess weight loss (%EWL) was > 70% at 1 year, and reached 81.4% at 5 years when 97% of the patients had a %EWL > 50%. Comorbidities were cured or improved in all patients. Conclusion: DS was very effective for the treatment of the morbid obesity in the SO patients.

Background Duodenal switch (DS) is one of the most effective techniques for the treatment of morbid obesity and its co-morbidities, with mortality rate <1%, but with 9.4% morbidity rates (6.5% due to leaks). In our experience, leaks of the staple-line after sleeve gastrectomy (SG) are the most frequent sites of fistula formation and conservative treatment usually takes a long time.We present our experience in the treatment of gastric leaks with coated self-expandable stents (CSES). Methods 6 patients had gastric leaks at the gastroesophageal (GE) junction after SG or DS. One patient had a symptomatic gastro-bronchial fistula. Stents were placed by the interventional radiologist under fluoroscopic control and removed endoscopically. In one case, we used an uncoated Wallstent. In two patients, percutaneous microcoil embolization of the fistula was added. Results The patient treated with the Wallstent required a total gastrectomy 6 months after placement of the uncovered stent. In the other 5 patients, coated stents were successfully removed and the gastric leaks completely sealed. Conclusions CSES are proposed as an alternative therapeutic option for the management of GE junction leaks in bariatric surgery with good results in terms of morbidity and survival.

Background: Duodenal switch (DS) is one of the most effective techniques for the treatment of morbid obesity and its related co-morbidities, with mortality rates of <1%, but with 9.4% morbidity rates (6.5% due to leaks). We present our experience with 9 patients operated with a DS, who later underwent total gastrectomy (TG) for complications of the sleeve gastrectomy. Methods: From 1994 to March 2006, 846 patients underwent the DS. 9 patients (1%) underwent TG; 5 were due to gastric leak at the angle of His, 2 were related to leakage at the doudeno-ileal anastomosis (DIA), 1 was for stenosis of the gastric sleeve, and 1 for a gastroparesis. In 3 cases, the DS was the second bariatric operation. Full restoration of bowel anatomy was attempted in all patients. Results: TG has been the final solution for gastric complications of the DS in 9 (1%) of our 846 patients. In all cases, bowel anatomy has been restored, and there was no mortality. Postoperative courses have been difficult and hospital stays have been long in all patients (mean 4.5 months; range 1-10 months), with several episodes of re-do surgery after the TG. The actual BMI and %EBMIL are acceptable. Conclusions: TG successfully treated all 9 cases with life-threatening complications and difficult reinterventions after DS, without mortality. Restoration of bowel anatomy was done in all cases, with good final results.

Background: The duodenal Switch (DS) is a variant of the biliopancreatic diversion (BPD) for the surgical treatment of morbid obesity. Materials and Methods: The laparoscopic DS (LapDS) operation is described, and the early surgical outcomes of 16 patients are reported. Results: Postoperative stay was 5 to 8 days. Local wound infection at a trocar site was the most common local complication. Conclusion: LapDS is an advanced, complex and feasible technique in bariatric surgery.