Thirty months experience with laparoscopic adjustable gastric banding

Introduction: Since June 1996 we performed laparoscopic adjustable silicone gastric banding (LASGB), because of low invasivity, absence of malabsorption, reversibility, and postoperative regulation. Materials and Methods: Criteria included body mass index (BMI) >40 or >35 with serious obesity-related conditions. 154 patients underwent LASGB, BMI ranged from 35 to 65.7 (mean 43.7+/-6.2). Results: The laparoscopic procedure was successfully completed in 150 patients (97.4%). One patient was converted to the laparotomic procedure because of hepatomegaly; 4 patients had to be converted for gastric laceration during the laparoscopic approach. In one of these patients, the band was removed 7 days later for sepsis, followed by an uneventful postoperative course. The mean length of postoperative hospitalization was 2.3+/-0.9 days. Per cent of excess weight loss was 42.5+/-22.4 after 1 year. Conclusions: LASGB was feasible and effective

Peritoneal and subcutaneous absorption of insulin in type I diabetic subjects

We and others have shown that in type I diabetes, ip insulin delivery results in lower free insulin levels than sc delivery. The aim of this study was to compare the rate of appearance of insulin in the peripheral circulation during ip and sc insulin administration in type I diabetes, in steady state and nonsteady state. To do this, we determined free insulin levels during ip or sc infusion as well as the impulse response of the insulin system after iv injection of a 6-nmol bolus of insulin. Twelve hours after a constant basal insulin infusion (5.5 +/- 1.4 nmol/h) was started, five C-peptide-negative type I diabetic subjects showed a lower systemic rate of appearance of insulin (expressed as a percentage of the administered dose) with ip than sc administration (27 +/- 6% vs. 40 +/- 10%; P < 0.001). In nonsteady state, when the infusion rate was increased from basal to 15 nmol/h (0-150 min) and subsequently to 42 nmol/h (150-300 min), the percent increase in insulin's systemic rate of appearance was higher with ip than sc infusion (P < 0.05 from 60-150 min; P < 0.01 from 150-300 min), indicating faster absorption. Thus, we conclude that insulin is more rapidly absorbed from the peritoneal cavity than from sc tissue. However, with ip administration, a sizable amount of insulin, once absorbed, is extracted before reaching the peripheral circulation, most likely by the liver. This is indirect evidence that ip insulin delivery results in a portal-peripheral insulin gradient in humans

The bilio-intestinal bypass

Background: Since 1990, we adopted the bilio-intestinal bypass (BIBP) for all morbidly obese patients eligible for a malabsorption procedure. Since 2001 we used laparoscopic technique. Methods: 148 patients, mean age 35.4 (18-63) years; preoper- ative mean weight kg 148.3 (104-225); mean preoperative BMI 54.1 kg/m2 (40-66.2); mean follow-up 10 years (1-22). 83 patients underwent open and 65 laparoscopic BIBP. Laparoscopic BIBP was performed with five lap ports. Section of the jejunum 30 cm distal to the ligament of Treitz and of mesentery was made by a linear stapler. The cholecysto-jejunal anastomosis was completed with 45-mm linear stapler. A side-to-side anastomosis between the proximal jejunum and the last 12-18 cm of the ileum was cre- ated by firing a 60-mm linear stapler. On the excluded ileum, an anti-reflux valve system was hand-sutured. Results: 5 years postoperatively, mean weight was 89 (62-130) kg, mean BMI was 31 kg/m2 (24-41). Two patients of the 65 laparoscopic patients were converted to open surgery for adhe- sions post-appendectomy. The main late complications were inci- sional hernia (19.3%) and abdominal bloating (2.9%). The rever- sal and conversion rate was 6.5%. There was no death. Conclusions: Our experience showed that 5 years post-BIBP, the weight loss was satisfactory in 90.7% of patients. Using laparoscopic technique, it is possible to reduce pain, in-hospital time, respiratory and thromboembolic complications, convales- cence and incisional hernia

Bioenterics intragastric balloon : 7 years experience

Background: Since 1998, we adopted in our clinical practice for treatment of obesity and morbid obesity the BioEnterics Intragastric Balloon (BIB\uae): it has the characteristics of an \u201cideal gastric balloon\u201d (Tarpon Springs Workshop, 1987). Methods: Since March 1998, we placed by the endoscopic approach 518 BIB in 480 patients affected by obesity and morbid obesity; 124 male and 356 female, mean age 41.6 years (18-72), mean weight kg 116.9 (67-229), mean BMI 42 kg/m2 (27.3-81.1). All our patients underwent diet of 1000 Kcal/day and treatment with antisecretory drugs. Results: The mean weight lost was 14.69 kg and the mean reduction in BMI was 5.11 kg/m2. Weight lost was greater in male morbidly obese (BMI >40). Weight lost was accompanied by an improvement of the diseases associated with obesity: diabetes, arterial hypertension and sleep apnea. Conclusions: The best indications for BIB were: morbidly obese patients (BMI >40) and super-obese patients (BMI >50) in prepa- ration for bariatric surgery; obese patients with BMI 35-40 with co- morbilities in preparation for bariatric surgery; obese patients with BMI 30-35 with a chronic disease otherwise unresolved; patients with BMI <30 only in a multidisciplinary approach

Adjustable gastric banding for morbid obesity. Our experience

BACKGROUND: The adjustable gastric banding is considered the most common procedure in Europe for the treatment of morbid obesity. We report our experience with this procedure, that was introduced in our Departments of Surgery since 1993. METHODS: From December 1993 to December 2004, 684 morbid obese patients (139 males and 545 females) underwent adjustable gastric banding (AGB) in our departments of Surgery. The first 323 patients were operated with perigastric procedure, the following 361 patients with pars flaccida technique. 601 patients were operated with laparoscopic approach, 83 with open approach. The average follow-up is 5 years. RESULTS: Mean BMI decreased from 42.2 to 34 Kg/m2 five years after the operation, with an EWL of 54 %. The main early complications were: intraoperative gastric perforation (5 patients, 1 of which repaired in laparoscopy); hemorrhage from short gastric vessels (3 patient, repaired in laparotomy). The major late complications were: intragastric band migration (7 patients); irreversible dilatation of the gastric pouch (42 patients, treated surgically with band removal or repositioning). CONCLUSION: In our experience laparoscopic adjustable gastric banding is a safe and effective procedure, suitable to most patients, and should be considered as the first choice in the surgical treatment of morbid obesity

Laparoscopic adjustable gastric banding for the treatment of morbid (grade 3) obesity and its metabolic complications : a three-year study

Weight loss ameliorates arterial hypertension and glucose metabolism in obese patients, but the dietary approach is unsatisfactory because obesity relapses. Durable reduction of body weight, obtained through major nonreversible surgical procedures, such as jejunal and gastric bypass, allows improvement of glucose metabolism and arterial blood pressure in morbid (grade 3) obesity. Laparoscopic adjustable gastric banding (LAGB) is a minimally invasive and reversible surgical procedure that yields a significant reduction of gastric volume and hunger sensation. In this study, 143 patients with grade 3 obesity [27 men and 116 women; age, 42.9 \ub1 0.83 yr; body mass index (BMI), 44.9 \ub1 0.53 kg/m 2; normal glucose tolerance (NGT; n = 77); impaired glucose tolerance (IGT; n = 47); type 2 diabetes mellitus (T2DM; n = 19)] underwent LAGB and a 3-yr follow-up for clinical (BMI, waist circumference, waist to hip ratio, and arterial blood pressure) and metabolic variables (glycosylated hemoglobin, fasting insulin and glucose, insulin and glucose response to oral glucose tolerance test, homeostasis model assessment index, total and high-density lipoprotein cholesterol, triglycerides, uric acid, and transaminases). At baseline and 1 yr after LAGB, patients underwent computerized tomography and ultrasound evaluation of visceral and sc adipose tissue. One-year metabolic results were compared with 120 obese patients (51 men and 69 women; age, 42.9 \ub1 1.11 yr; BMI, 43.6 \ub1 0.46 kg/m 2; NGT, n = 66; IGT, n = 8; T2DM, n = 46) receiving standard dietary treatment. LAGB induced a significant and persistent weight loss and decrease of blood pressure. Greater metabolic effects were observed in T2DM patients than in NGT and IGT patients, so that at 3 yr glycosylated hemoglobin was no longer different in NGT and T2DM subjects. Clinical and metabolic improvements were proportional to the amount of weight loss. LAGB induced a greater reduction of visceral fat than sc fat. At 1-yr evaluation, weight loss and metabolic improvements were greater in LAGB-treated than diet-treated patients. We conclude that LAGB is an effective treatment of grade 3 obesity in inducing long-lasting reduction of body weight and arterial blood pressure, modifying body fat distribution, and improving glucose and lipid metabolism, especially in T2DM