<figure><img src="image_71.png" /></figure>

SAGES POSTER ABSTRACTS

**Bariatric Surgery – P055**

**CT SCANNING IS NOT SENSITIVE FOR FINDING INTERNAL HERNIAS AFTER GASTRIC BYPASS.** Nestor de la Cruz-Munoz MD, Luz Velez MD, Cristina Torres MD, Constantino Pena MD, Surgical Weight Loss Institute

**Introduction:** Internal hernias after gastric bypass may present acutely with bowel obstruction, or in the office setting as intermittent post prandial pains and vomiting. Computed tomographic (CT) evaluation of internal hernia has been reported as 80% sensitive in the literature, but these studies have only discussed acutely presenting patients. There is nothing in the literature that discusses the use of CT scan in diagnosing chronic internal herniations.

**Materials and Methods:** We retrospectively reviewed the CT scans of 26 patients who had undergone laparoscopic GBP and subsequent internal hernia repair for chronic abdominal pains. All had obtained CT scans prior to the hernia repair.

**Results:** Of the 26 patients, the Radiologist interpretation of the scans was normal in each case. The scans were reviewed by a radiologist retrospectively with the knowledge that the patients had internal hernias clinically and he felt that there were very subtle findings in the CT scans at best.

**Discussion:** Diagnosis of internal hernia with CT remains difficult. Post prandial abdominal pain with associated vomiting should alert the clinician to the possibility of an internal hernia. CT scanning cannot be counted on to accurately evaluate a patient for a chronic internal hernia without an acute small bowel obstruction.

**Bariatric Surgery – P056**

**GASTRIC BYPASS IS SAFE IN PATIENTS WITH BMI>50.** Nestor F de la Cruz-Munoz MD, Luz Velez MD, Juan C Cabrera MD, Cristina Torres MD, Surgical Weight Loss Institute

**Background:** The super obese are at an extremely high risk for major comorbidities that greatly reduce life span and quality of life. Surgical weight loss provides an effective treatment for morbidly obese patients. There have been concerns that super obese patients should not undergo gastric bypass due to the potential for high rates of complications. This study will evaluate the perioperative complication rate, in a private practice bariatric center, of gastric bypass surgery on patients with a BMI >50 and compare it to published norms in the literature for all morbidly obese patients.

**Study Design:** Outcomes from 277 roux-en-y gastric bypass procedures (with one converted to an open procedure for loss of abdominal domain with a very large ventral hernia) on super obese patients with an initial mean BMI of 56 where studied retrospectively. Postoperative complications and changes in BMI were evaluated.

**Results:** The data was obtained from the patients initial, 1 month, 3 month, 6 month, and 12 month follow up visit. The average BMI decreased from 56 to 37. There were a total of 14 perioperative complications. Of those, there were only four major complications requiring reoperation. There was one death. This occurred in the patient that had to be converted to open. The skin and subcutaneous tissue over the hernia sac necrosed and the patient passed away from the ensuing sepsis.

**Conclusion:** In our high volume bariatric surgical center, the perioperative complication rates were comparable to published studies for all bariatric patients. We conclude that laparoscopic gastric bypass surgery can be safely performed on the super obese patient without significant increased risk.

**Bariatric Surgery – P057**

**DOES MENTAL HEALTH ILLNESS AFFECT THE ASSESMENT AND OUTCOME OF BARIATRIC SURGERY?** B H Dickie MD, C Johnsson-Stoklosia, P D Davey MD, D W Birch MD, Department of Surgery, University of Alberta, Centre for Advanced Minimally Invasive Surgery, Royal Alexandra Hospital, Edmonton, Alberta, Canada

**OBJECTIVES:** With bariatric surgery, a profound stress, both personal and emotional, is caused by both the operation as

well as the dramatic life changes that follow. Recent literature quotes rates of up to 50% of patients seeking bariatric surgery have a diagnosis of a psychiatric illness. There is minimal data to support whether these patients should undergo surgery or if they do any different than patients without mental health issues. Our clinical experience suggests careful selection of these patients can lead to successful outcomes. We have reviewed the female patients assessed and treated in our bariatric clinic who have had bariatric surgery and a psychiatric illness.

**METHODS:** A retrospective review of the female patients from our bariatric clinic patient database was completed from patients assessed and treated from October 2002-July 2006.

**RESULTS:** 386 new female patient consults were evaluated in our multidisciplinary clinic. 157 (40.7%) patients had reported a mental health (MH) issue (self reported (20), treated by a mental health professional (114) or on psychiatric medications (61)). The breakdown of diagnoses are as follows: 134 depression, 3 postpartum depression, 24 anxiety disorder, 3 ADHD, 14 eating disorders, 8 bipolar, 5 obsessive compulsive, 9 borderline personality, 1 schizophrenic and 31 had other diagnoses. Of these patients, 77 patients have undergone bariatric surgery (49% - same as non-MH patients) and 4 patients are undergoing medical screening for possible OR. Only one patient did not qualify for surgery because of her MH illness. Mean BMI pre-operatively was 53.52 (49.86 in non-MH patients). Following surgery, 9 MH patients were lost to follow-up (11.6%) (versus 4 (3.5%) in non MH patients) even with intense intervention to locate these patients. Overall, both MH and non-MH patients have comparable outcomes in weight loss.

**CONCLUSIONS:** Patients with mental health disease are more difficult to assess and follow. But if screened appropriately and with intense follow-up arranged can have successful outcomes with bariatric surgery.

**Bariatric Surgery – P058**

**LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING WITH TRUNCAL VAGOTOMY: DOES THIS AUGMENT WEIGHT LOSS?** Kristen R Earle-Hardcastle MD, Matt B Martin MD, David H Newman MD, Ben T Hoxworth MD, Central Carolina Surgery, PA; Moses Cone Health Systems, Greensboro, NC

**OBJECTIVE:** Since the vagus nerve provides important motor, sensory and hormonal signals regulating satiety and hunger, vagotomy may augment weight loss in patients receiving adjustable gastric bands. This is the first study to examine the effect of laparoscopic truncal vagotomy in combination with laparoscopic adjustable gastric banding (LAGB) and its effect on weight loss and reduction of comorbidities.

**METHODS:** Since May 2006, 11 of the 25 IRB approved patients have undergone laparoscopic gastric banding with truncal vagotomy. The adequacy of vagotomy was assessed by intraoperative and pathologic inspection and endoscopic Congo Red test under IV baclofen stimulation. Outcome measures include total weight loss, BMI changes, percent excess body weight lost, operative morbidity and adverse events.

**RESULTS:** All patients report anorexia. There were no adverse events and all patient were discharged in < 23 hours. No patients reported diarrhea, bloating, or other historical side effects from vagotomy. Average pre-op BMI was 43.25 (+/- 3.27). Average age was 46 years. 9/11 patients were female. At 3 months we observed a reduction in BMI of 4.34. We have seen over 2 pound per week weight loss in these patients with no issue of hunger. Most patients do not request an adjustment at five weeks like standard LAGB patients. We have observed and will later report a significant reduction in comorbidities.

**CONCLUSION:** Although further study is needed, LAGB efficacy for weight loss and reduction of comorbidities may be augmented when combined with a truncal vagotomy.
## Bariatric Surgery - P059

### CHANGES IN BODY TISSUE COMPOSITION IN MORBIDLY OBESE PATIENTS FOLLOWING BARIATRIC SURGERY,

Ayesha Hossain BS, Aaron Eckhauser MD,Pamela Marks MS,James Isbell MD,Phillip Williams BS,Kong Chen PhD,Alfonso Torquati MD,William Richards MD,Naji Abumrad MD, Vanderbilt University Medical Center

**Purpose:** To document the time dependent changes in body weight and tissue composition following laparoscopic Roux-en-Y gastric bypass (LRYGB).

**Methods:** We used dual energy x-ray absorptiometry (DEXA) to measure changes in regional (trunk, arms and legs) in fat mass (FM) and lean body mass (LBM) in 9 morbidly obese subjects prior to and 6 and 12 months following LRYGB.

**Results:** As expected body mass index (BMI) dropped after surgery (from 48.1 to 34.9 at 6 months and 31.1 at 12 months, p<.005). Weight loss was significantly greater (77%) during the first 6 months versus the second 6 months (23%). Waist-to-hip ratio (WHR) dropped from .92 (preoperatively) to .86 and .84 at 6 and 12 months, respectively. The changes in body weight were associated with equal losses in FM and LBM in the first 6 months, but the losses were predominantly in FM during the subsequent 6 months. The changes in LBM during the first 6 months were predominantly from the trunk (Table 1).

<table><thead><tr><th></th><th></th><th>Arms (kg)</th><th>Trunk (kg)</th><th>Legs (kg)</th><th>Total</th></tr></thead><tbody><tr><td rowspan="2">0-6M</td><td>Loss FM</td><td>2.5</td><td>7.9</td><td>7.8</td><td>18.2</td></tr><tr><td>Loss LBM</td><td>1.0</td><td>14.4</td><td>4.0</td><td>19.4</td></tr><tr><td rowspan="2">7-12M</td><td>Loss FM</td><td>1.3</td><td>5.6</td><td>2.5</td><td>9.4</td></tr><tr><td>Loss LBM</td><td>.2</td><td>.4</td><td>1.4</td><td>.2</td></tr></tbody></table>

**Conclusion:** The losses in lean body mass during the first 6 postoperative months following LRYGB are significant and equal to the losses in fat mass. The majority of losses in LBM during this period are derived from trunk muscles. These changes require reassessment of our strategies to prevent lean body mass loss postoperatively and require readjustment of our exercise strategies to curb trunk muscle weight loss.

## Bariatric Surgery - P060

### ROLE OF COLOR DOPPLER SONOGRAPHY IN THE DIAGNOSIS OF DEEP VEIN THROMBOSIS IN MORBIDLY OBESE PATIENTS UNDERGOING LAPAROSCOPIC GASTRIC

**BYPASS**, Tomas Escalante-Tattersfield MD,Olga Tucker MD,Patricio Fajnwaks MD,Samuel Szomstein MD,Raul J Rosenthal MD, The Bariatric Institute, Cleveland Clinic Florida

**Background.** Deep venous thrombosis (DVT) is a significant cause of morbidity after surgery. Obesity is a known risk factor for DVT. In patients undergoing surgery for morbid obesity reported incidence is up to 3.8%. Early detection and treatment is essential to prevent fatality form a pulmonary embolus and local long-term effects of the postthleptic limb. Color Doppler sonography (CDUS) is currently the most accurate technique for evaluating DVT. The objective of this study was to define the incidence of DVT in our population of morbidly obese patients after laparoscopic Roux-en-Y gastric bypass (LRYGB). Materials & Methods. A retrospective review of prospectively collected data was performed on 500 consecutive morbidly obese patients who underwent LRYGB. Each patient received 5000 units of subcutaneous unfractionated heparin preoperatively, and every 8-hr after surgery for the first 24-hr. Subcutaneous enoxaparin was then administered every 12-hr until patient discharge. Sequential compression devices (SCD) were applied to both legs intraoperatively and continued until the patient was fully ambulatory. 24-hr postoperatively, all patients underwent a lower extremity CDUS. Patients were subsequently followed at 2, 8, 12, 24 and 52 weeks after surgery. Results. Of the 500 patients, 74% were female, with a mean age of 43 years (range 18-78). The mean preoperative BMI was 49 kg/m2 (range 35-90) Mean operative time was 96 min (range 50-196). CDUS was positive for a right common femoral DVT in only one patient (0.2%). This patient had no

clinical features suggestive of DVT. The remaining 499 patients had no clinical or sonographic evidence of DVT. During the follow up period, no further DVTs were detected.

**Conclusions.** Although the DVT in this study was low at 0.2%, clinically asymptomatic DVT may lead to morbidity and even mortality; we recommend CDUS in all morbidly obese patients undergoing LRYGB. A perioperative protocol for DVT thromboprophylaxis is essential in all bariatric surgical programs.

## Bariatric Surgery - P061

### RISK FACTORS FOR MORBIDITY FOLLOWING LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS,

Alex Escalona MD,Rodrigo Munoz MD,Camilo Boza MD,Gustavo Perez MD,Fernando Pimentel MD,Sergio Guzman MD,Luis Ibanez MD, Departamento de Cirugia Digestiva. Pontificia Universidad Catolica de Chile

**Introduction:** Laparoscopic Roux-en-Y gastric bypass (RYGBP) is one of the alternatives of choice in the surgical treatment of the morbid obesity. Preoperative risk assessment is important to establish an adequate risk-benefit ratio. The aim of this study was to identify risk factors of morbidity after laparoscopic RYGBP. Methods and procedure:

Information was obtained from the prospective database of all patients who underwent laparoscopic RYGBP at our institution from August of 2001 to May of 2006. Univariate and multivariate logistic regression were performed to identify risk factors for postoperative morbidity. Factors examined included demographic characteristics of patients, comorbidities and learning curve. Results: During this period,1052 patients underwent laparoscopic RYGBP, 796 (76 %) women. Mean age and preoperative body mass index (BMI) were 37 ± 11 years and 41 ± 5 Kg/m2 respectively. The mean operative time was 114 ± 39 minutes. The mean hospital stay was 4,0 ± 2,5 days. In 12 patients (1,1 %) conversion to open surgery was needed. There were no deaths. Postoperative complications were observed in 78 patients (7,4 %). In 24 of them (2,1 %) reoperation was needed. Postoperative complications were observed in 49 (9,3 %) and 29 (5,5 %) patients of the first and second consecutive half of patients respectively (p=0,019). Mean preoperative BMI in patients with and without postoperative morbidity was 42,3 ± 5,8 and 40,9 ± 5,1 Kg/m2 respectively (p=0,046). Multivariate logistic regression showed that BMI was an independent risk factor for postoperative morbidity (odds ratio = 1,05; 95% confidence interval, 1,01-1,09). Conclusion: Postoperative morbidity was lower in the second half of patients. Mean BMI was higher in patients who developed postoperative complications. Preoperative BMI was the only independent risk factor for postoperative morbidity after laparoscopic RYGBP.

## Bariatric Surgery - P062

### EFFECT OF ADVANCED AGE ON OUTCOMES AFTER LAPAROSCOPIC GASTRIC BYPASS,

Rafael Fazylov MD,Eliana Soto MD,Stephen Merola MD, New York Hospital at Queens

As laparoscopic gastric bypass is being performed more frequently on older patients, we ask the question whether advanced age has an effect on the rate of perioperative complications and degree of postoperative weight loss. A retrospective cohort study was performed of 30 patients > or = 55 years old and 230 patients < 55 years old who underwent laparoscopic gastric bypass surgery during August 2002 and August 2006 at our institution. We compared complication rates, degree of weight loss and improvement of comorbidities between the two groups.

## Bariatric Surgery - P063

### ENDOSCOPIC TREATMENT OF JEJUNOJEJUNAL OBSTRUCTION AFTER ROUX-EN-Y GASTRIC BYPASS

**SURGERY**, Derek G Fong MD,Edward C Mun

MD,Christopher C Thompson MD, Brigham and Women's Hospital

Narrowing at the jejunojejunal (JJ) anastomosis may occur as a complication after Roux-en-y gastric bypass (RYGB) surgery and present as small bowel obstruction. Although a
<figure><img src="image_72.png" /></figure>

SAGES POSTER ABSTRACTS

surgical approach has been advocated as definitive therapy, here we report the first successful endoscopic treatment of a JJ obstruction with balloon dilation.

**Case Report:** A 50-year-old female presented six weeks after laparoscopic RYGB bypass surgery with four days of obstructive symptoms including nausea, vomiting, and abdominal pain. The patient's surgical anatomy consisted of a 75 cm Roux limb and a side-to-side jejujejunostomy constructed with a blue load EndoGIA stapler. At the time of presentation, a CT scan of the abdomen and pelvis revealed dilation of the defunctionalized stomach, duodenum, and multiple jejunal loops down to the level of the JJ anastomosis consistent with a small bowel obstruction.

Upper endoscopy was performed using a pediatric colonoscope (PCF-160, Olympus, Tokyo, Japan). At the level of the JJ anastomosis, a stenotic aperture prevented passage of the endoscope into the afferent (pancreaticobiliary) limb. Under fluoroscopic guidance, a guidewire was advanced into the afferent limb and CRE balloon (Boston Scientific, Natick, MA) was used to sequentially dilate the afferent portion of the anastomosis to a diameter of 12 mm with the resultant decompression of the afferent limb. There were no procedural complications and the patient has remained clinically well without further obstructive symptoms at ten months post procedure.

**Discussion:** Obstructive complications may develop after RYGB bypass surgery at the level of the gastrojejunal (GJ) anastomosis and JJ anastomosis. Narrowing at the JJ anastomosis is most often caused by adhesions. Bowel obstruction due to JJ narrowing occurs in less than 5% of patients after laparoscopic RYGB surgery.

Surgical treatments for JJ obstruction include laparoscopic bypass of the obstruction site and lysis of adhesion.

Although endoscopic dilation of GJ strictures has been effectively performed with good long term results, this case represents the first report of endoscopic therapy for a JJ obstruction. Endoscopic dilation should be considered as a viable alternative to surgical treatment of JJ obstructions after RYGB surgery.

## Bariatric Surgery - P064

**RESTRICTIVE SLEEVE GASTRECTOMY**, Eldo E Frezza MD, Texas Tech University Health Sciences Center

**Objectives** Sleeve gastrectomy (SG) has acquired more publicity in the United States. Some physicians have now been using it as a single stage procedure.

It was suggested at the last SAGES meeting that the stomach should be approximately a 32 French bougie to get good results.

Some papers have described injury secondary to bougie. In this paper, we describe a sleeve gastrectomy done under direct vision with a 29 French endoscope. This allows us to continually monitor our staple line and our stomach while performing the operation.

**Methods** From June 2005 to June 2006, we considered the experience of 10 patients in which we performed a SG with endoscopic guidance. The body mass index (BMI) ranged between 52 and 72 with a mean of 65. Age range was between 48 to 65 with an average of 57. Six patients were male and four were female. All of the patients had multiple comorbidities including diabetes, high blood pressure, high cholesterol, high triglycerides, sleep apnea, joint pain, dysmenorrhea, difficulty urinating and others. All of the patients underwent a SG with endoscopic guidance.

**Results** None of the patients had complications with the staple line after the operation. Only two patients had skin infection. Excess weight loss at 6 months was about 30% for all patients with a decrease on average BMI of 50 to 68.

**Conclusion** SG appears to be safe and effective for weight loss. The advantage of endoscopic guidance is decreased potential bougie injury.

## Bariatric Surgery - P065

**THE IMPACT OF MORBID OBESITY ON THE REGIONAL ECONOMY**, Eldo E Frezza MD, Mitchell S Wachtel MD, Bradley T Ewing PhD, Texas Tech University Health Sciences Center; Texas Tech University

**Objectives** Obesity's impact on a region's economy has not been fully analyzed. An economic model was derived to evaluate the cost of obesity in terms of lost business output, employment, and income.

**Methods** We analyzed the charts of all of our patients who underwent laparoscopic gastric bypass and laparoscopic banding over two years. Input-output analysis estimate margins, the purchase prices for goods and services, and regional purchase coefficients, the percent of spending by local suppliers, were used to model the regional economy. Collected patient data, used in conjunction with IMPLAN model data, were used to estimate, on a regional basis, an industry-by-industry formulation of input-output accounts to calculate multipliers, the impact of the economic costs of the obese to the general economy.

**Results** For our region, the impacts total over $1.3 billion, about 2.5% of total gross state product. Total labor income impacts are nearly $200 million, $1,660 of output income per household and $245 of labor income per household. Obesity cost over 7,300 jobs and cut state and local tax revenues by over $48 million.

**Conclusion** Governmental measures to combat this menace are warranted.

## Bariatric Surgery - P066

**LAPAROSCOPIC GASTRIC BANDING AND STOMACH REDUCTION (GBSR)**, Eldo E Frezza MD, Mitchell S Wachtel MD, Texas Tech University Health Sciences Center

**Objectives** Laparoscopic gastric banding (LGB) and sleeve gastrectomy (SG) are established bariatric surgical procedures.

**Methods** A single-procedure, combined laparoscopic gastric banding/sleeve gastrectomy (GBSR), was devised. Technique and results in the first ten patients is reported.

**Results** Ten patients, one man and nine women, with a median BMI of 66.5 kg/m2 (range 64-79 kg/m2) and multiple serious co-morbidities, underwent GBSR without complications. At six months, BMI decreased by a median 28% (range 19%-34%). The percent excess weight loss (EWL) was 24.4 + 1.6. All patients were discharged within one day. No complications or deaths occurred. Only two patients required outpatient band adjustments, both at five months after GBSR.

**Conclusion** GBSR appears to be a safe bariatric surgical procedure with faster weight loss in the first 6 months than LGB alone and less need of band adjustments.

## Bariatric Surgery - P067

**REOPERATIVE LAPAROSCOPIC ADJUSTABLE GASTRIC BAND (LAP-BAND®) SURGERY CAN BE SAFELY PERFORMED AT A FREE STANDING AMBULATORY SURGERY CENTER.**, Mark A Fusco MD, LifeShape Advanced Bariatrics Center of Florida and Melbourne Same Day Surgery Center.

**Introduction:** Several authors have documented the appropriateness of performing LAP-BAND® surgery in the outpatient setting. Our outpatient based bariatric program previously reported short term safety data of the author's first 100 LAP-BAND® procedures demonstrating the ability to safely perform outpatient LAP-BAND® without inpatient LAP-BAND® experience. Our hypothesis was that reoperative surgery could be performed in an ambulatory surgery center with similar short term safety.

**Methods and Procedures:** Our prospectively collected patient database was retrospectively reviewed to assess 30 day mortality, morbidity, and hospital admission rates for nine patients undergoing reoperative LAP-BAND® surgery.

**Results:** Since May 2005 nine patients underwent reoperative surgery. These included three patients who had bands replaced after previously being removed, two band removals, two band replacements (one stage) for prolapse, and two patients who were converted from other previous
bariatric surgeries (1 vertical band gastroplasty, 1 Molina fixed band). All nine surgeries were completed as planned. All patients were discharged the day of surgery. Follow up at 90 days was 100 percent. There were no mortalities. There were no major morbidities. There was one port site infection requiring antibiotics. The 30 day readmission rate was 0%.

**Conclusion:** Reoperative LAP-BAND® surgery can safely be performed in the outpatient setting. The acceptance of LAP-BAND® as an outpatient procedure has several potential advantages including decreased cost, improved patient ambulation, and a better microbial environment.

## Bariatric Surgery - P068

**EFFECT OF THE LAP BAND SYSTEM ON COMORBID CONDITIONS IN SEVERELY OBESE ADOLESCENTS: EARLY RESULTS.**, Alberto S Gallo MD, Carlos A Galvani MD, Racquel Smith-Bueno MD, Maria V Gorodner MD, Mark Holterman, Allen Browne MD, Ai-Xuan Le Holterman MD, Nancy Browne MD, Santiago Horgan MD, Department of General Surgery, University of Illinois at Chicago.

**Background:** Obesity in adolescent patients increases the likelihood of adult obesity, and also the prevalence of weight-related comorbidities. Laparoscopic adjustable gastric banding (LAGB) is a safe procedure that offers a good option for attaining weight loss. However, there is scarce data in the literature regarding the influence of weight loss on adolescents? comorbidities.

To determine if LAGB related weight loss is associated with improvement of comorbidities.

**Methods and Procedures:** Between December 2001 and March 2006, 27 patients underwent LAGB. The following data were analyzed: Perioperative data, postoperative complications, body Mass Index (BMI), % excess body weight loss (%EBWL). Patients were given a questionnaire after surgery to evaluate resolution/improvement of Asthma, Depression, Dyslipidemia, Gastroesophageal Reflux Disease (GERD), Hypertension (HTN), Menstrual Irregularities, Osteoarthritis (OA), Sleep Apnea and Type 2 Diabetes Mellitus. Values are expressed as mean ± standard deviation.

**Results:** Twenty one (78%) patients were female and 6 (12%) were male. Of these, 23 patients were Caucasian and 4 African American. Mean age was 18±1.7 years (14-20), and preoperative BMI was 49±9.7 kg/m? (38-81). Operative time was 45±15 min, blood loss 7±4 ml (5-20), and length of hospital stay 15.6±8 hrs (5-26). There was no mortality. The most common long term complication was pouch enlargement occurring in 7 (26%) patients. Five of these patients (72%) were managed conservatively and 2 (28%) required surgery. A total of 92% of patients were in active follow up at 17±12 months. The mean %EBWL at 3, 6, 9, 12, 24, 36 and 48 months was 22±14, 34±23, 28±18, 41±24, 42±13, 42±26 and 41.5 respectively. The overall number of comorbidities before surgery was 41 (1.5 /patient); decreasing to 10 (0.4 /patient) postoperatively (p = 0.000). Resolution/improvement was observed in: Asthma 75%, Depression 100%, Dyslipidemia 50%, GERD 50%, HTN 71%, Menstrual irregular. 100% (one patient taking birth control pills), OA 80%, Sleep apnea 63%, Type 2 DM 33%.

**Conclusion:** With very low perioperative morbidity and no mortality, LAGB is a safe and effective tool for attaining weight loss in adolescents, potentially leading to an early control of obesity-related comorbidities. Nevertheless, band-related complications seem to be more frequent in this cohort. Longer follow up is needed to support these preliminary findings

## Bariatric Surgery - P069

**UNREVELING THE MYTH: SIZE DOES MATTER. THE VG BAND DECREASES THE INCIDENCE OF COMPLICATIONS AFTER LAP BAND SURGERY.**, Carlos A Galvani MD, Maria V Gorodner MD, Racquel Bueno MD, Alberto S Gallo MD, Federico Moser MD, Celia Chretien RN, Allen Mikhail MD, Santiago Horgan MD, University of Illinois at Chicago

**BACKGROUND:** The laparoscopic placement of the adjustable gastric banding (LAGB) has evolved overtime.

Since March 2004 two types of bands have been used in our practice: the 10 cm and the 11 cm band (VG). It has been said that the liberal use of the VG band reduces the incidence of postoperative obstruction. However the impact on long term complications such as pouch enlargement (PE) and band slippage (BS) remains unknown.

**OBJECTIVES:** To report our initial results after the introduction of the larger band in our practice.

**METHODS:** Between 3/04 and 6/06, 435 patients underwent LAGB. Patients were divided into 2 groups. Group A: 10 cm band, and Group B: VG band. Patients with less that 3 months follow up were excluded. Selection of the type of band was done intraoperatively, according to the amount of fat pad present.

**RESULTS:**

<table><thead><tr><th></th><th>Group A</th><th>Group B</th><th>p</th></tr></thead><tbody><tr><td>Patients</td><td>121</td><td>313</td><td></td></tr><tr><td>BMI preop. (kg/m²)</td><td>42±6</td><td>47±9</td><td></td></tr><tr><td>PE</td><td>22 (18%)</td><td>22 (7%)</td><td></td></tr><tr><td>BS</td><td>3 (2%)</td><td>0 (0%)</td><td></td></tr><tr><td>% EWL (%)</td><td></td><td></td><td></td></tr><tr><td>• 3 months</td><td>25±12</td><td>21±11</td><td>N S</td></tr><tr><td>• 6 months</td><td>40±18</td><td>29±16</td><td>&lt; 0.05</td></tr><tr><td>• 9 months</td><td>46±20</td><td>35±20</td><td>&lt; 0.05</td></tr><tr><td>• 12 months</td><td>47±19</td><td>42±23</td><td>N S</td></tr><tr><td>• 18 months</td><td>49±19</td><td>45±27</td><td>N S</td></tr></tbody><tfoot><tr><td colspan="4">(*) %excess weight loss</td></tr></tfoot></table>

**CONCLUSIONS:** our initial results showed that the liberal use of the VG reduces the incidence of postoperative complications. However the % EWL was slower in this group of patients.

## Bariatric Surgery - P070

**POST-OPERATIVE ROBOTIC TELEPRESENCE REDUCES LENGTH OF STAY IN PATIENTS UNDERGOING NON-COMPLICATED LAPAROSCOPIC GASTRIC BYPASS FOR MORBID OBESITY.**, Alex Gandsas MD, Christina Li MD, Stuart Shindel MD, Marvin Tan MD, Kennedy Gabregiorgish MD, Sinai Hospital of Baltimore

**Background:** Several studies have shown that the average length of stay (LOS) following laparoscopic gastric bypass (LGBP) ranges between 2 to 4 days. As our program matured, we tested the impact of robotic telepresence as an adjunct to standard post operative rounds in regard to LOS in patients undergoing non-complicated LGBP for morbid obesity. Robotic telepresence allows physicians to conduct patient rounds in the hospital, consult with staff and access patient's data by using a combination of two-way real time streaming video, wireless protocols and the Internet.

**Methods:** We retrospectively reviewed 376 patients who underwent a non-complicated LGB from January 2004 to August 2006. Patients suffering from a major post operative complication were excluded from this study. Qualifying patients were grouped into those assessed by standard bedside rounds only (Group A) and those assessed by combining remote robotic with standard bedside rounds (Group B). Groups were matched for age, gender, body mass index and number of co-morbidities. Discharge criteria included adequate urine output, ambulation, oral intake and pain control.

**Results:** In Group A, 76% (218 patients), 17% (48 patients) and 4% (12 patients) were discharged on post operative day 2, 3 and 4 respectively, while in Group B, 76% (68 patients), 20% (18 patients) and 3% (3 patients) were discharged on post operative day 1, 2 and 3 respectively. The average LOS was 2.36 days in Group A and 1.27 days in Group B. Readmission rate within 30days following discharge was 6% for Group A and 1% for Group B.

**Conclusions:** Our data indicates that post-operative robotic telerounding can safely reduce LOS in patients undergoing non-complicated LGB and may help with the overall hospital through-put

## Bariatric Surgery - P071

**WHAT IS THE OPTIMAL BOWEL PREP FOR PATIENTS WHO HAVE UNDERGOED GASTRIC BYPASS?**, Susan A Garand DO, Gary Wease MD, S Salimi MD, Dilip Desai MD, Michigan State University Department of Surgery, Flint Campus

**Introduction:** Patients who have undergone bariatric gastric bypass procedures could be predicted not to tolerate high-

<figure><img src="image_73.png" /></figure>
<figure><img src="image_74.png" /></figure>

# SAGES POSTER ABSTRACTS

volume colonic bowel preparations (?bowel prep?) prior to colonoscopy. Anecdotal experience in our community appeared to support that concern. Review of the current literature yielded no established protocol regarding the optimal bowel prep after gastric bypass surgery. The aim of our study was to identify the most easily tolerated prep as well as its effectiveness in the gastric bypass patient who subsequently required colonoscopy.

**Methods:** We conducted a retrospective chart review of patients who underwent gastric bypass and subsequent colonoscopy. For each patient, we recorded the type, patient tolerance (as told to and recorded by the nursing staff) and adequacy of the bowel prep (as described in the procedure note). The interval between gastric bypass and colonoscopy was also recorded.

**Results:** We identified 21 patients who underwent both gastric bypass and subsequent colonoscopy. Bowel preps employed included Golytely (n=7), Golytely plus Dulcolax tabs (n=3), Fleets Phosnosoda alone (n=5), Fleets Phosnosoda plus enema (n=2), Fleets Phosnosoda plus Dulcolax tabs (n=1), Visicol tablets (n=1), and Half-lytely plus Dulcolax tabs (n=2). The time frame between gastric bypass and colonoscopy ranged from 1 month to 5 years. All but 2 patients tolerated their bowel prep. Both of these patients had colonoscopy within 3 months after gastric bypass and were given high-volume preps.

**Conclusion:** Our study suggests that high-volume bowel prep is not tolerated in the early period following gastric bypass but is well tolerated later in the post-bypass period. Because our study included a small sample size and variation in bowel preps, we plan to conduct a prospective, randomized study comparing standard 2-gallon bowel prep to smaller volume Fleets Phosnosoda bowel prep.

## Bariatric Surgery - P072

**FOLLOW-UP OF 121 MORBIDLY OBESE PATIENTS AFTER GASTRIC BYPASS SURGERY, Ke Gong MD, Michel Gagner MD, Alfons Pomp MD, Taghreed Almahmeed MD, Sergio Bardaro MD, Department of Surgery, Beijing Shijitan Hospital and Department of Surgery, New York Presbyterian Hospital, Weill Medical College**

**Objective:** The aim of our study is to evaluate the changes of nutrition and metabolism of the patients with morbid obesity after laparoscopic Roux-en-Y gastric bypass surgery(LRYGBP).

**Methods:** A study of 121 patients diagnosed with morbid obesity who undertook LRYGBP in New York Presbyterian Hospital. Serum Iron(Fe), Calcium(Ca), Zinc(Zn), Selenium(Se), VitaminA(VitA), 25-hydroxy VitaminD3(VitD), VitaminB12 (VitB12) and Parathormone (PTH) were measured at 6-month, 12-month and 24-month after LRYGBP.

**Results:** It took this research approximately sixty-nine months from June 1999 to February 2005 to complete. Among the total 121 patients, 40 males and 81 females underwent LRYGBP surgery. They had a mean age of 46 years (range 22&#65374;67). The mean BMI prior to LRYGBP was 47.00±7.15 kg/m2 (range 30.65&#65374; 76.60kg/m2). After the surgery, the mean BMI was 33.79±6.06 kg/m2 (range 21.70&#65374;52.76 kg/m2). The mean BMI was decreased&#65288; P<0.001&#65289; after 6 month of the surgery. Within the following two years, the serum Fe, Ca, Zn, Se, VitA, VitD, VitB12 were all at the normal level. Although the serum Zn, Se, VitA of some patients were decreased, they were near the healthy level with the supplementation help for more than one year. Whilst serum PTH remained continuously at a higher than normal level.

**Conclusions:** This research concludes that Laparoscopic Roux-en-Y Gastric Bypass surgery is reliable and safety to the patients suffering from morbid obesity. Meanwhile, the serum Calcium, Zinc, Selenium metabolisms and PTH are altered in the patients following LRYGBP. Multi-Vitamin and microminerals supplementation are strongly advised in all patients.

## Bariatric Surgery - P073

**NATURE VS NATURE: IDENTICAL TWINS AND BARIATRIC SURGERY, J Hagedorn MS, J Morton MD, Stanford Department of Surgery**

**BACKGROUND:** Genetics and environment both play a role in weight maintenance. Twin studies may help clarify the influence of nature vs. nurture in weight loss. We present the largest US experience with identical twins undergoing bariatric surgery

**METHODS:** We retrospectively reviewed the charts of four sets of monozygotic twins who underwent laparoscopic roux en y gastric bypass and laparoscopic adjustable gastric banding at three different institutions. BMI and comorbidities were examined pre- and post-operatively and complications were recorded.

**RESULTS:** All four sets of twins are female, live together, and have the same profession. Set 1 had near identical weight loss patterns after open gastric bypass surgery in 1996 (preop: 320/312 to 2 years: 180/180, and 10 years 237/235). The two patients within Set 1 also both needed cholecystectomies within the first year post operatively. In Set 2, these twins underwent laparoscopic gastric bypass surgery and also had required cholecystectomies in the first post-operative year. Set 2 also experienced near identical weight loss at 1 year (% BMI Loss, 37.7 vs. 37). Set 3 underwent Lap Band placement with two different surgeons with differing amounts of weight loss at 6 months (% BMI loss, 7.4 vs. 19.4). Finally, Set 4 underwent laparoscopic gastric bypass with 2 year % BMI loss of 39 vs. 34. The twin who lost less weight proportionally lived apart from her twin and their extended family for a year and during that time her weight loss was less than the twin living with her family.

**CONCLUSION:** Two sets of monozygotic twins had identical responses to bariatric surgery and complications. The other two sets of identical twins had differential weight loss results due to differences in surgical approach and social support. While genetics do exert a strong influence on weight maintenance, this case series demonstrates the effect of social support and post-operative management upon post-operative weight loss in the presence of identical genetics.

## Bariatric Surgery - P074

**WEIGHT LOSS OUTCOMES UTILIZING A STANDARDIZED ROUX-LIMB LENGTH: A COMPARISON BETWEEN SUPER-OBESE AND NON-SUPER OBESE PATIENTS UNDERGOING LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS, Soo Hwa Han MD, Nicole Basa MD, Amir Mehran MD, Lubna Suleman MD, Darshni Vira BS, Ian Soriano MD, Carlos Gracia MD, Erik Dutson MD, University of California at Los Angeles, David Geffen School of Medicine**

**Background:** In the laparoscopic Roux-en-Y gastric bypass (LRYGB), the ideal alimentary limb length is unknown. Controversy exists regarding whether various body mass index (BMI) ranges require different alimentary limb lengths for optimum weight loss results. At our institution, an 80 centimeter (CM) roux-limb is created for both the super-obese (BMI greater than or equal to 50) and non-super obese (BMI less than 50) patients. We hypothesized that this approach will result in comparable weight loss results.

**Methods:** Between January 2003 and June 2006, 835 LRYGBs were performed. One year follow-up data was available in 246 patients. The patients were divided into two groups: Group I - 167 patients with BMI<50 kg/m2 (average= 43, range 35-49); and group II - 79 patients with BMI > 50 kg/m2 (average= 54, range 50-82). Their demographic, comorbidity, excess body weight loss (%EBWL) and perioperative complications were collected into a prospective database and retrospectively reviewed.

**Results:** The two groups were comparable in age, sex, pre-operative comorbidities and postoperative complications. The average EBWL was 76% (range 8-100%) in group I and 54%(range 16-99%) in group II (p=.0075).

**Conclusion:** With a standardized 80 CM roux-limb, weight loss results were inferior in the super obese group when compared to their non-super obese counterparts. These
<figure><img src="image_75.png" /></figure>

results have prompted us to make a programatic change by
creating a longer roux-limb length in super obese patients.

## Bariatric Surgery - P075

**IMPORTANCE OF CLINICAL INDICATORS IN DETECTING POSTOPERATIVE COMPLICATIONS FOLLOWING LAPAROSCOPIC SLEEVE GASTRECTOMY**, SM Han MD,WW Kim MD, Department of Surgery, Kangnam CHA Hospital, College of Medicine, Pochon CHA University, Seoul, South Korea.

**Background:** A significant and drastic complication of laparoscopic sleeve gastrectomy (LSG) in morbidly obese patients is gastric staple line leakage. The aim of our study is to evaluate the efficacy clinical data for detecting postoperative complications after LSG.

**Methods:** The study enrolled 150 consecutive patients undergoing LSG performed from January 2003 to July 2006. When abnormal data (heart rate jÅ 110/min, or temperature jÅ 37.5jÉ) were detected on postoperative day 1, laboratory tests (blood, urine, Chest X-ray, abdominal sonogram) and water soluble gastrografin UGIS were performed to detect the postoperative complications after LSG (group 1). Patients (group 2) who had normal postoperative clinical data were compared with group 1.

**Results:** From the total of 150 patients who underwent LSG, nine patients (6%) had postoperative complications. Two patients had major complications: 1 leakage (0.6%) and 1 delayed bleeding (0.6%), and 4 patients had minor complications in group 1. But, major complications had not detected in group 2 (p < 0.01). Heart rate and body temperature in group 1 was significantly faster and higher than group 2 (p < 0.01). Especially, 2 patients who had major complications had severe tachycardia over 120 beats per minute (bpm). However, when high temperature was present, it was no high grade fever in all cases (> 39jÉ).

**Conclusions:** Evidence of tachycardia or high body temperature may be useful to detect major complications. Also, routine postoperative gastrografin upper gastrointestinal series (UGIS) following LSG may be not beneficial. We recommend laboratory test and UGIS when clinically indicated.

## Bariatric Surgery - P076

**EARLY IMPROVEMENT IN GLUCOSE HOMEOSTASIS AFTER ROUX-EN-Y GASTRIC BYPASS IS WEIGHT-INDEPENDENT,** Erik N Hansen MD,Ed Yoo BS,Marks Pamela MS,J K Wright MD,W O Richards MD,A Torquati MD,Naji N Abumrad, Vanderbilt University School of Medicine

**Purpose:** To investigate the early post-op changes in glucose, insulin and the Insulin Resistance index of the Homeostasis Model Assessment (HOMA-IR) after roux-en-Y gastric bypass (RYGB) and to determine a) the earliest time points for improvements and b) whether the improvements are purely related to weight loss.

**Methods:** Fasting serum samples and anthropometric data were collected from eight subjects (3M, 5F) undergoing RYGB before operation and again 3-5 days, 3 weeks, and 6 weeks postop.

**Results:** Body mass index (BMI) did not change at 3-5days after operation (52+6 and 51+7kg/m2, pre-op and 3-5days post-op, respectively; p=0.2). However, at 3 and 6 weeks post-op, BMI fell 10% (p<0.0001) and 13% (p<0.0001), respectively. Fasting blood glucose fell to 94% (p=0.03), 90% (p=0.1), and 86%(p=0.002) of preop levels at 3-5days, 3weeks, and 6weeks postop, respectively. Fasting insulin fell to 64% (p=0.08), 71%(p=0.08), and 52% (p=0.001) of the preop level at 3-5days, 3weeks, and 6weeks, respectively. Accordingly, HOMA-IR showed improvement over the early postop period (figure 1), falling to 65% (p=0.04), 69%(p=0.02) and 52%(p=0.001) of preop levels at 3-5days, 3 weeks, and 6 weeks after the operation, respectively.

**Conclusion:** Insulin and glucose balances improve early after RYGB. Our data support a weight-independent period of HOMA-IR improvement followed by a weight-related improvement in glucose homeostasis.

<figure><img src="image_76.png" /></figure>

## Bariatric Surgery - P077

**CANCER IN THE GASTRIC REMNANT PRESENTING EARLY AFTER GASTRIC BYPASS,** Jason L Harper MD,Derrick Beech MD,David S Tichansky MD,Atul K Madan MD, University of Tennessee Health Science Center, Memphis, TN and Meharry Medical College, Nashville, TN

Gastric carcinoma in the gastric remnant after roux-en-y gastric bypass (RYGB) is rare but has been reported. The time from surgery to the presentation of carcinoma has ranged from 5 to 22 years postoperatively in the literature. A significant concern with RYGB is the difficulty evaluating the gastric remnant. Due to this difficulty some surgeons recommend routine preoperative evaluation via endoscopy. Although most findings are benign, abnormalities are frequently discovered during screening endoscopy in bariatric surgery patients.

We present a 45-year-old female who had an open RYGB. Approximately one year later she presented with abdominal pain and distension. CT scan diagnosed a gastric remnant mass causing gastric outlet obstruction and subsequent exploration revealed unresectable metatstatic gastric adenocarcinoma. A decompressive gastrostomy tube was placed, and she was treated with chemotherapy and radiation. She eventually expired due to metastatic disease. She did not have a preoperative endoscopic evaluation.

This case illustrates the importance of endoscopic evaluation prior to RYGB and it signifies the need for a high index of suspicion in order to recognize this problem at an early stage.

## Bariatric Surgery - P078

**PREOPERATIVE BARIATRIC SCREENING AND TREATMENT OF H. PYLORI,** Charles W Harten MD,Daniel S Remine,Tananchai A Lucktong MD, Carilion Clinic, Roanoke, Virginia, USA

**INTRODUCTION:** A preoperative screening and treatment program of pre-existing H. pylori infections was hypothesized to reduce postoperative bariatric complications and associated morbidity as the role of H. pylori in gastrointestinal symptomatology and peptic ulcer disease is known.

**METHODS:** A single institution, single surgeon, IRB approved, retrospective chart review was done for 183 consecutive patients undergoing an initial laparoscopic gastric bypass over a 40-month period from December, 2003 to April, 2006. The patients were divided into an H. pylori untested group (125 patients) and a tested and treated if indicated group (58 patients). Patient demographics and incidences of hospital re-admissions, GI ulceration and bleeding, perforated viscous, esophagogastroduodenoscopy, and foregut symptoms were documented at routine follow-up and emergency room visits. Results were subjected to analysis with Fisher's exact test.

**RESULTS:** Seven patients (12%) in the tested group were positive for H. pylori and treated. The number of GI ulcers and bleeding, EGDs, ER visits, and hospital re-admits were not statistically different; however, in the untested group, six patients (5%) presented with viscous perforation compared with none in the tested and treated group (p=0.09). Demographics for both groups were similar and both had a large number of non-specific foregut symptoms.

**CONCLUSION:** Preoperative H. pylori screening should continue, especially in geographically high prevalence areas, as data suggest that the incidence of viscous perforation may be reduced with preoperative treatment if indicated.
<figure><img src="image_77.png" /></figure>

# SAGES POSTER ABSTRACTS

## Bariatric Surgery - P079

**REVERSE ANGLE OF HIS DISSECTION: A NEW TECHNIQUE FOR LAP. BAND PLACEMENT**, Aaron B Hoffman, Colin J Powers MD, Alan C Geiss, Melanie L Howard RPA-C, Syosset Hospital- Laparoscopy Center, North Shore- Long Island Jewish Health System, Syosset, New York

**Purpose:** Laparoscopic adjustable gastric banding has become an important component of bariatric surgery with ever increasing utilization. However, the placement of the laparoscopic adjustable gastric band (LAGB) can prove difficult in the morbidly obese patient secondary to multiple anatomic factors. While traditional lesser curve dissection methods include the peri-gastric and the pars flaccida techniques, a novel approach is now described with allows for placement of the LAGB using a reverse Angle of His dissection to position the LAGB.

**Methods:** Two separate cases are presented in which access to the hepatogastric ligament and right crus were not possible secondary to challenging anatomy. As access to the retrogastric plane was not possible through the traditional lesser curve dissection options, a custom modified 10mm laparoscopic esophageal disector was used to open the phrenogastric ligament on the greater curvature at the Angle of His and dissect into the retrogastric plane in reverse fashion.

**Results:** In both of the described cases, the reverse Angle of His dissection technique allowed for placement of the LAGB in morbidly obese patients with challenging anatomy. Both patients experienced uneventful peri-operative periods and have progressed well during their post-operative follow-up. The method for step-by-step performance of this innovative technique is described and illustrated.

**Conclusions:** While the LAGB can be a highly effective tool for surgical treatment of the morbidly obese, this modality can pose significant technical difficulties and requires advanced laparoscopic skill. Though the lesser curve dissection techniques remain the easiest and preferred means to place the LAGB, this new approach allows for successful and safe placement of the LAGB when exposure to the right crus is limited and the lesser curve approach to the retro-gastric plane cannot be established.

## Bariatric Surgery - P080

**UNCOMMON CAUSE OF CHRONIC NAUSEA, VOMITING AND REGURGITATION FOLLOWING LAPAROSCOPIC GASTRIC BYPASS: LONG JEJUNAL DIVERTICULUM**

**SYNDROME**, Dennis Hong MD, Jay Jan MD, Emma J Patterson MD, Laparoscopic Bariatric Surgery Program, Legacy Health System and Oregon Weight Loss Surgery LLC

**Objective:** To describe an unusual cause of chronic nausea, vomiting and regurgitation following laparoscopic gastric bypass procedure.

**Methods:** From January 2000 to September 2006, 778 patients underwent laparoscopic antecolic, antegastric gastric bypass at our institution. Using our IRB-approved, prospectively maintained database, we identified all patients who presented with chronic nausea, vomiting and regurgitation that required resection of the jejunal diverticulum at the gastrojejunal anastomosis. All values are given as median (range).

**Results:** 4 patients presented with chronic nausea, vomiting and regurgitation following laparoscopic gastric bypass that required resection of an elongated jejunal diverticulum. All patients underwent investigations including bloodwork, and endoscopy. The first 3 patients underwent CT scans and upper GI. Median age was 41.5 yrs (16 yrs). All patients underwent a laparoscopic antecolic, antegastric gastric bypass with a 25-mm EEA circular staple technique. Median time to symptoms after gastric bypass was 11 months (15 mo). Time to correct diagnosis was 3 months (2.5 mo). Median length of jejunal diverticulum was 5.5 cm (1 cm) All patients had complete resolution of symptoms following resection of the elongated jejunal diverticulum.

**Conclusion:** An elongated jejunal diverticulum is a rare cause of chronic nausea, vomiting and regurgitation. Resection of the diverticulum results in immediate relief of symptoms

## Bariatric Surgery - P081

**RECURRENCE OF MESENTERIC DEFECTS AFTER CLOSURE IN ROUX-EN-Y GASTRIC BYPASS**, William W Hope MD, Albert Y Chen MD, Keith S Gersin MD, Timothy S Kuwada MD, Todd Heniford MD, Carolinas Medical Center

**Background:** Numerous studies have documented the risk of developing small bowel obstruction after Roux-en-Y gastric bypass (RYGBP). Debate still remains concerning the importance of closing all mesenteric defects. We reviewed patients who have undergone gastric bypass with suture closure of their jejunojejunostomy mesenteric defects. In patients who required subsequent surgery, the mesenteric defect was examined intraoperatively. This study documents the status of the mesenteric closure at reoperation.

**Methods:** A retrospective review of patients undergoing abdominal surgery after RYGBP was performed from August 1999 to August 2006. The operative notes from subsequent surgeries were reviewed to examine the status of the mesentery at the jejunojejunostomy.

**Results:** Fifteen patients underwent surgery between 6-19 months after either open (8) or laparoscopic (7) gastric bypass. Patients lost between 52-137 pounds between operations. Surgeries were performed for various indications including ventral hernia (7), cholecystectomy (3), abdominal pain (3), and small bowel obstruction (2). All 15 patients were found to have open mesenteric defects at surgery despite previous closure. All of the defects were incidental findings and not causal factors in reoperation.

**Conclusions:** Routine suture closure of mesenteric defects after gastric bypass is not an effective means of permanent closure. This finding is probably secondary to the extensive weight loss and loss of fat within the mesentery in this patient population.

## Bariatric Surgery - P082

**A CANADIAN EXPERIENCE COMPARING LAPAROSCOPIC GASTRIC BYPASS TO ADJUSTABLE GASTRIC BAND**, Quoc H Huynh MD, Shea Chia MD, Hagen A John MD, Starr David MD, Klein Laz MD, Urbach David MD, Humber River Regional Hospital

**Authors/Institutions:** Quoc H. P. Huynh, MD; Shea Chia, MD; David Starr, MD; Laz V. Klein, MD; John A. Hagen, MD; David Urbach, MD. Minimally Invasive Surgery Program, University of Toronto.

**Introduction:** Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic adjustable gastric band (LAGB) procedures are common practice in the United States. In Canada, the experience is limited with few institutions doing either and fewer still doing both. It is important to compare the two in Canada because LRYGB is covered by publicly available health insurance, while LAGB is not. Patients having LAGB may have better outcomes compared to LRYGB, because having to pay for the procedure themselves might serve to make patients more motivated and invested in its success.

**Methods:** Retrospective chart review of consecutive LRYGB and LAGB from April 2005 to April 2006 at Humber River Regional Hospital in Toronto, Canada. We measured patient demographics, weight loss, percentage of excess weight loss, change in body mass index (BMI), early (<30d) and late (>30d) complications, reoperations, medical comorbidity, and patient satisfaction.

**Results:** A total of 124 patients were evaluated. 39 (31%) and 85 (69%) underwent LAGB and LRYGB, respectively. Demographic factors were similar between the two groups. Compared with LRYGB, patients who underwent LAGB experienced less percent excess weight loss (27% vs 55% EWL), but fewer complications (13% vs 21%).

**Conclusion:** Financial motivation does not translate into better outcome for LAGB compare to LRYGB.
## Bariatric Surgery - P083

### REMOVABLE IVC FILTERS IN HIGH RISK BARIATRIC

PATIENTS, Isaias Irgau MD, Gail m Wynn MD, Todd Harad MD, Christiana institute of advanced surgery and Delaware vascular Associates

**Background:** Pulmonary embolism is a leading cause of early mortality following bariatric surgery. Several experienced bariatric surgeons have advocated the prophylactic use of IVC filters in a sub-group of bariatric patients with higher than average risk for Pulmonary Embolism. The enthusiasm for this approach has been tempered by the long term morbidity associated with traditional permanent IVC filters. The advent of removable IVC filters has made this prophylactic intervention more appealing. We report our experience with the prophylactic use of removable IVC filters, in high risk bariatric patients.

**Methods:** Retrospective analysis of medical records, of patients selected to have prophylactic removable IVC filters prior to primary bariatric procedures.

**Results:** From June 2003 to September 2005, 42 patients underwent preoperative removable Gunther-Tulip IVC filters placement. Mean age 47yrs, mean BMI 54.1, Female 75% Male 25%. Reason for IVC filter - history of venous thromboembolism and/or venous stasis disease. All placements by single vascular surgeon in the radiology suite or the OR on day of bariatric surgery except for 9 cases done one or more days prior to bariatric surgery. Mean length of filter stay prior to removal 16.6 days, range 9-30 days. Filters removed successfully, 38 out of 42. Failed attempt at retrieval 1 case, patient refusal 1 case. Clinical decision to leave filters in place 2 instances, development of DVT/PE 1 patient and long postoperative illness 1 patient. No other filter related complications.

**Conclusion:** Removable IVC filters are safe in the high risk bariatric patients and allow for a proactive prophylaxis against Pulmonary Embolism while avoiding the long term morbidity of permanent filters.

## Bariatric Surgery - P084

### PREDISPOSING FACTORS FOR BAND SLIPPAGE IN LAP-BAND PATIENTS, Jay C Jan MD, Matt Mihlbauer BS, Dennis Hong MD, Emma J Patterson MD, Department of Surgery, Legacy Health System, Portland, Oregon

**Background:** Band slippage or gastric prolapse is a well-known complication of gastric banding. Predisposing factors have not been characterized.

**Methods:** All patients who underwent laparoscopic adjustable gastric banding (LAGB) by a single surgeon at Legacy Health System over a two-year period were identified from a prospectively-maintained database. All patients received either a 10 cm or 11 cm Lap-Band System using the pars flaccida technique. Occurrence of band slippage, preoperative BMI, excess weight loss (EWL), crural repair, and gastric band size were analyzed.

**Results:** From November 2002 to November 2004, 223 patients underwent LAGB. Mean follow-up was 26 months. 195 patients received the 10 cm Lap-Band and 28 patients received the 11 cm Lap-Band. 13 patients (5.8%) were diagnosed with band slippage. The mean time interval between primary surgery and diagnosis of slippage was 9 months (range 9 to 43). There was no significant difference in age (45 vs. 46 years; P = 0.743) or male sex (8 vs. 20%; P = 0.471) between patients with slippage and without slippage.

<table><thead><tr><th></th><th colspan="2">Slip (N=13)</th><th>No Slip (N=210)</th><th>P</th></tr></thead><tbody><tr><td>Preop BMI</td><td>46.8</td><td>51.8</td><td>0.043</td><td></td></tr><tr><td>11 cm Lap-Band</td><td>0%</td><td>13.3%</td><td>0.380</td><td></td></tr><tr><td>Crural Repair</td><td>23.1%</td><td>11.0%</td><td>0.182</td><td></td></tr><tr><td>EWL at 12 mo</td><td>41.7%</td><td>33.4%</td><td>0.075</td><td></td></tr><tr><td>Follow-up (mo)</td><td>29</td><td>25</td><td>0.237</td><td></td></tr></tbody></table>

**Conclusion:** Band slippage is associated with lower preoperative BMI and possibly faster early weight loss. Increased use of the 11 cm Lap Band may reduce the incidence of band slippage.

## Bariatric Surgery - P085

### PREVENTION OF MORTALITY FROM PULMONARY EMBOLISM IN BARIATRIC PATIENTS THROUGH IVC FILTER

PLACEMENT, Clark M Kardys MD, Mark L Manwaring MD, Michael Stoner MD, Michael Barker MD, Kenneth MacDonald MD, John Pender MD, William Chapman MD, East Carolina University Department of Surgery

**Objective:** The placement of inferior vena cava filters (IVCF) is thought to provide protection from fatal pulmonary embolism (PE) despite causing an increased incidence of deep venous thrombosis (DVT). We hypothesize that our practice of IVCF placement in bariatric patients helps prevent fatal PE and we present our analysis of that data. PE is the leading cause of death after gastric obesity procedure (GOP) approximating 0.5%. It has been our practice to offer IVCF placement to those with BMI > 60 kg/m2, profound immobility, history of venous thromboembolism (VTE), hypercoagulable state, or venous stasis. Methods: Hospital and outpatient records of all 494 patients who underwent GOP in our practice from January 1, 2004 to May 31, 2006 were reviewed. Patients who underwent IVCF placement under fluoroscopy or intravascular ultrasound (IVUS) were selected. Co-morbidities, outcomes, and complications were recorded. Results: Thirty-two patients (mean BMI = 67±3.18 kg/m2) underwent GOP (9 laparoscopic, 23 open) with peri-operative IVCF placement by fluoroscopy (5) or IVUS (27). Indications were history of VTE (4), hypercoagulable state (3), and profound immobility (25). Technical success rate of placement was 97.3% with one filter placed in the iliac vein using IVUS. Three patients (9.4%) were diagnosed with DVT postoperatively. Computed tomography detected PE in one of those patient (3.1%) two months postoperatively. There were two deaths with a mean follow up of 302±35.5 days. Autopsy excluded VTE as the cause of death in those patients. Conclusions: Our population is at greater risk for VTE than the standard GOP population due to immobility from unusually large BMI or hypercoagulable state. IVUS guided IVCF placement allows for added PE prophylaxis in high risk and super obese patients who may not be candidates for IVCF placement due to table weight limits or fluoroscopic penetration limitations. This technique make IVCF placement possible in almost any patient. This data suggests IVCF placement is effective in preventing fatal PE. A larger patient population will be required to prove statistical efficacy or to determine the risk relationship between prevention of mortality from PE and contribution to DVT related morbidity from IVCF placement.

## Bariatric Surgery - P086

### LAPAROSCOPIC BARIATRIC SURGERY IN JAPAN: SINGLE SURGEON'S SERIAL EXPERIENCES, Kazunori Kasama MD, E Kanehira MD, A Umezawa MD, T Kurosaki MD, T Ohshiro MD, Yotsuya Medical Cube

**Background:** Bariatric Surgery was very rare in Japan But recently obesity become a social problem. We performed the first Laparoscopic Roux en Y Gastric Bypass (LRYGB) in Japan in Feb. 2002. In this study we present our experiences.

**Methods:** From Feb.2002 to Sep. 2006, 102 patients underwent Lap Bariatric surgery by single surgeon. 93 cases of LRYGB, 6 cases of Lap sleeve gastrectomy (LSG) and 3 cases of LAGB in Japan. Median preoperative BMI of LRYGB was 43.7, LSG: 60.5, LAGB: 40.

**Results:** Our procedures of LRYGB: Antecolic antegastric method. Gastrojejunostomy methods were 1 circular stapler, 8 liner stapler, 83 Hand sewn Double-layer. Leakage occurred in 1 circular stapler case, and 3 Hand-sewn cases. Stenosis occurred in 1 linear stapler case and 6 hand-sewn cases. No mortality within 30 days postope. was observed. Average weight loss 30kg, BMI-11.5, 60% of Excess body weight loss was achieved at 6 mo. after surgery, 42kg, BMI - 15.8, %EWL 79% at one year, 43kg BMI -16.4 %EWL 74% at two year after surgery and 53kg, BMI-19, %EWL 80% at four years after surgery. Almost every co-morbidity are improved after surgery. Two LRYGB with simultaneous remnant gastrectomy were done for the patients with family history of
<figure><img src="image_78.png" /></figure>

# SAGES POSTER ABSTRACTS

gastric cancers. And one case of double balloon endoscope was safely done at three years after LYRGB for examination of remnant stomach.

Six cases of LGB were done as 1st procedure for two stage operation or solo procedure as alternative of LAGB. At 3 mo., average weight loss25 kg, BMI -9.0, %EWL 30%. At 6 mo., weight loss 29kg BMI -13 %EWL 25%.

LAGB results are at 3Mo., -14kg BMI -5.5, %EWL 32%, at 6Mo.-19kg BMI -7.5, %EWL 43% and at 9Mo.: -23kg BMI -9.0 %EWL 52%.

**Conclusion:** LRYGB shows superior results to other operations even in Japan. Japan is high risk region of gastric cancer but simultaneous remnant gastrectomy for high gastric cancer risk case and double balloon endoscope can be done safely. Lap Band is the least perioperative complications?@Sleeve gastrectomy will be the one of the option for restrictive procedures in Japan.

## Bariatric Surgery - P087

**SUBCLINICAL DIABETIC GASTROPARESIS MAY CONTRIBUTUE TO POOR OUTCOMES AFTER LAPAROSCOPIC GASTRIC BAND**, Ajay Goyal MD, Catherine A Boulay MD, Overlook Hospital Summit, New Jersey

**Introduction:** The subset of patients who do not tolerate the laparoscopic adjustable band remains an elusive patient population to identify before surgery. Diabetes Mellitus, a common co-morbid condition in bariatric patients, is frequently associated with gastroparesis. We propose screening for diabetic patients to identify subclinical forms of diabetic gastroparesis which may be exacerbated by placement of a band.

**Methods:** We retrospectively reviewed our last 175 bariatric cases performed over two years in a community hospital setting. Patients were closely followed post-operatively with interviews and questionnaires, to evaluate improvements in co-morbid conditions and to elicit post-operative problems.

**Results:** Of the 175 patients reviewed, 100 patients underwent laparoscopic gastric bypass (57%) and 75 patients (43%) laparoscopic adjustable band. Eleven (15%) of the 75 gastric band patients had diabetes. One diabetic patient underwent conversion of gastric band to bypass after 18 months of aggressive postoperative management for inadequate weight loss with nausea & vomiting, despite normal findings on UGI and endoscopy. A second diabetic patient is undergoing evaluation for similar complaints. This problem was not seen in any of our non-diabetic gastric band patients or any gastric bypass patients.

**Conclusions:** Diabetic patients without obvious signs of gastroparesis prior to surgery may be at risk for developing dysmotility problems after placement of a gastric band. A preoperative evaluation to detect subtle forms of gastric dysmotility will be discussed. Gastric bypass is an alternative for bariatric patients at risk for complications of diabetic gastroparesis.

## Bariatric Surgery - P088

**BARIATRIC SURGERY IN PATIENTS OVER 65 YEARS IS SAFE WITH ACCEPTABLE MORBIDITY**, Ashutosh kaul MD, Thomas Sullivan, Dominick Artuso MD, Edward Yatco MD, Thomas Cerabona MD, New York Medical College

Aim of this presentation is to communicate our results of bariatric surgery in patients over 65 years (seniors) of age at a single center.

This is a retrospective analysis of prospectively maintained data from a tertiary care center. Data was analyzed from 1999 till august 2006. All cases were done by bariatric surgeons and by fellowship trainees under their guidance. Of the 1217 cases done in that period 30 bariatric procedures were done in senior patients.

<table><thead><tr><th></th><th>Under 65</th><th>over 65</th></tr></thead><tbody><tr><td>cases</td><td>1187</td><td>30</td></tr><tr><td>BMI</td><td>49.37</td><td>46.55</td></tr><tr><td>Lap bands</td><td>152</td><td>12</td></tr><tr><td>Gastric bypass</td><td>1024</td><td>18</td></tr><tr><td>Readmission rat</td><td>6.2%</td><td>0%</td></tr></tbody></table>

There were a higher percentage of seniors who opted for

the band in comparison to younger patients. The number of seniors undergoing bariatric surgery has increased dramatically in our series. While there were no cases in years 1999, 2001 and 2002 the percentage has increased in the later years (2000=1 case only, 2003=2.5%, 2004 = 3.1%, 2005 = 1.5% and 2006 = 5.9%). The excess weight loss in this series was 45% at one year. This partly reflects the advanced comorbidities, limited mobility and a higher percentage of these patients electing to have a lap band that continues to have weight loss over a longer period. There were 3 conversion to open surgery and 3 mortalities in patients under 65 years old only.

Our technique in creation of gastrojejunostomy is a four layered hand sutured technique and we bring the roux limb up in a retro-colic retrogastric route. We have had no leak from the GJ in over 970 cases. This series thus shows that bariatric surgery can be safely done in patients over 65 years old with acceptable morbidity

## Bariatric Surgery - P089

**THE USE OF RETRIEVABLE VENAL CAVAL FILTERS IN BARIATRIC PATIENTS**, Colleen Kennedy MD, Daniel Devun MD, Dennis Kay MD, William Richardson MD, Ochsner Medical Center

**Introduction:** The risk of a venous thromboembolic event (VTE) after bariatric surgery is significant and linked to multiple factors. The risk of increased morbidity/mortality with these events is seen in patients with a BMI >60, weight >400, immobility, personal history of DVT/PE. We evaluated the use of retrievable venal caval filters in this patent population for prevention of PE in the high-risk perioperative 3 months.

**Methods:** A retrospective review was performed examining all patients undergoing a laparoscopic gastric bypass from December 2003 to August 2006 at one institution. All patients undergoing preoperative IVC filter placement were examined.

**Results:** Between December 2003 and August 2006, 17 of 250 patients undergoing bariatric surgery underwent preoperative IVC filter placement prior to surgery. 15 patients had a Bard recovery filter placed and 2 patients had the Bard G-2 filter placed. All filters were placed percutaneously by interventional radiology. Indications for placement included BMI >60, weight >400 lbs (12), history of DVT/PE (4), wheelchair dependence (1). 10 patients had removal of the filter attempted at 3-6 months post bypass. Retrieval was successful in 8 of 10 patients (80%). A single VTE was seen postoperatively (DVT). No PEs were seen in our group.

**Conclusion:** The development of retrievable IVC filters allows a new option in the prevention of PE in the high-risk bariatric patient. Incorporation of this option in standard preoperative protocols for bariatric patients may provide improved protection from postoperative PE while avoiding the risks/complications associated with permanent vena caval filters.

## Bariatric Surgery - P090

**AGE RELATED RESOLUTION OF CARDIOVASCULAR COMORBIDITIES IN BARIATRIC SURGERY PATIENTS**, E Ketchum BS, Y Liu BS, J Hagedorn MS, B Encarnacion BS, DB Williams MD, J Morton MD, Stanford Department of Surgery

**Introduction:** Given that bariatric surgery is the only effective and enduring therapy for morbid obesity, bariatric surgery is now increasingly performed on older patients. Postoperative discharge without cholesterol, diabetes, or hypertension medications is common based on high rates of comorbidity resolution after surgery. We explored the degree to which older patients achieved cardiovascular comorbidity resolution as compared to younger patients.

**Methods:** A retrospective chart review of patients undergoing laparoscopic Roux en Y gastric bypass between July 2003 and June 2006 at the Stanford Hospital was conducted. Demographics, comorbidity resolution, cardiovascular risk factors, and weight loss in patients at or below and over the age of 50 were compared using Student's t-test and chi-squared analysis as appropriate.
**Results:** 489 patients were identified. One-year complete data were available for 153 patients (49 in the senior cohort of age>50 and 104 in the junior cohort of age < 50). The senior cohort and junior cohort were similar respectively in % female (78 vs. 84, p=.17) preop BMI (48 vs. 47, p=.34) and percent BMI loss at 1 year (31 vs 33, p=0.16) but the senior cohort had a higher mean of comorbid conditions (4.5 vs. 3.2, p<.01). The senior cohort demonstrated less improvement in cardiac risk factors at one year including reductions in cholesterol level at (15 vs. 33, p=.02), triglycerides (52 vs. 79, p=.27), and LDL (14 vs. 29, p=.03). The senior cohort had lower rates of comorbidity resolution for hypertension (65% vs. 78%, p=.04) and diabetes (72% vs. 91%, p=.04) at 12 months. The senior cohort also had worse levels of homocysteine (9.3 vs. 8.6, p=.21), lipoprotein A (3 vs. 2, p=.23), CRP (3.2 vs. 2.4, p=.19), and a comparable A1C level (5.6 vs. 5.6) at 12 months.

**Conclusions:** Improvements in pre-operative comorbidities are significantly less pronounced in older patients undergoing gastric bypass as compared to younger patients. It may not be appropriate to routinely discontinue lipid and hypertension medications in post-operative gastric bypass patients over the age of 50.

## Bariatric Surgery - P091

### INCISIONLESS ACCESS PORT INSERTION METHOD DURING LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING,
Eung K Kim MD, Sang K Lee MD, Department of Surgery,
College of Medicine, The Catholic University of Korea

**Objective:** Laparoscopic adjustable gastric banding (LAGB) is a relatively simple procedure with considerable weight loss outcome, sometimes comparable to Roux-en-Y gastric bypass. It is the most frequently performed bariatric procedure in Europe, Australia, and now, it is increasing in frequency in US. We have noticed that people willing to have LAGB are very concerned about the surgical scars after the procedure. Our team has developed a way to implant the access port without making an elongated incision. **Methods:** Eleven patients who underwent LAGB surgery with this method are included in this study. This method consists of introducing the access port through the umbilical trocar insertion site, thus obviating an elongated incision for the port insertion. After making a supraumbilical incision, about 10-cm long epifascial tunnel is made cephalad to umbilicus and slightly to the patient's left side; then, an 11-mm trocar is inserted after advancing 10 cm in epifascial plane, which is entered into the abdominal cavity through an oblique direction. Using this trocar incision site, it is possible to introduce the LAP-BAND (Inamed Health, Santa Barbara, CA). The rest of the trocars used are all 5-mm ones. After the insertion of LAP-BAND as described by Oj Brien and completing gastro-gastric stitches, the end of the tubing system is brought out through the optical trocar site. The access port is connected to the tube and placed on epifascial tunnel after undermining the space. **Results:** There were 8 females and 3 males in this study. Mean preoperative weight and BMI were 102.4±17.4 kg and 35.9±4.4 kg/m2, respectively. There were 2 patients who had seroma collections on port site, which were treated conservatively. No other wound-related complication occurred. Mean excess weight loss at 6 months was 32.9±12.8%. **Conclusions:** With this incisionless access port insertion method, there is no need for elongating one of the trocar wound. The access port is consistently well localized with palpation above the umbilicus and wound related complication is comparable to the traditional method. We recommend this approach for all morbidly obese patients who wish to have surgical scars similar to that of a laparoscopic cholecystectomy.

## Bariatric Surgery - P092

### LAPAROSCOPIC GASTRIC BYPASS SURGERY IN AN OBESE SLOW PROGRESSIVE INSULIN DEPENDENT DIABETIC PATIENT,
Dan Kolder MD, Vanessa Kuwajima-Smith
BS, Timothy Geiger MD, Mayfield Timothy MD, Bruce Ramshaw MD, Roger de la Torre MD, Stephen Scott MD,
University of Missouri Hospitals and Clinics

We report an obese 35 year old female who developed type I diabetes mellitus after being diagnosed with type II diabetes. Medical management of her diabetes mellitus had failed on multiple previous insulin and oral hypoglycemic regimens. She had a history of severe insulin insensitivity with insulin autoantibody titers (ICA) of 7.9 U/ml (normal range 0.0-1.0 U/ml). At the initial presentation, the patient's BMI was 33.97 kg/m2 and her HgA1C was 11.4%. The patient underwent a laparoscopic Roux-en-Y gastric bypass surgery. During the postoperative period, the patient's blood glucose levels remained in the 100-150 mg/dl, a significant improvement from the preoperative values of 360 mg/dl. In the following post-operative weeks, the patient converted to an euglycemic state, requiring only modest doses of insulin. There is a scarcity of case reports in the literature addressing the effects of gastric bypass surgery in obese autoimmune type I diabetics; the accumulation of such reports are important in understanding the relationship between obesity, insulin resistance, insulin autoantibodies, and the effect of weight loss in the glycemic control of such patients.

## Bariatric Surgery - P093

### A COMPARISON OF LAPAROSCOPIC AND OPEN REVISIONS OF ROUX-EN-Y GASTRIC BYPASS,
Ikram Kureshi MD, A
Tavakkolizadeh MD, K Clancy RN, Cesar Escareno MD, David Lautz MD, Brigham and Women's Hospital, Dept of Surgery,
Harvard Medical School, Boston, MA

**Introduction:** The ongoing proliferation of bariatric surgical procedures has led to increasing numbers of patients requiring revisional surgery. Previous studies have reported that the laparoscopic approach for revisional Roux-en-Y gastric bypass (rev-RYGB) is technically feasible with acceptable morbidity and mortality. No studies to date, however, have compared the laparoscopic and open approaches of rev-RYGB. This study compares the outcomes of the 2 different approaches in a single institution.

**Methods:** This is a retrospective review of 24 consecutive patients who underwent rev-RYGB by a single surgeon. Rev-RYGB was defined as any procedure involving revisional surgery to the stomach and ending with RYGB. Isolated small bowel procedures were excluded. Patient demographics, indications for revision, intraoperative and postoperative morbidity, length of stay, operative time, and 30 day mortality were reviewed in both groups. Student's t-test was used to compare the two groups.

**Results:** 16 procedures were performed open and 8 laparoscopically. The average age in both groups was 44. Female gender predominated in both the open (94%) and the laparoscopic (88%) groups. Original bariatric procedures were RYGB in all but two patients who had undergone vertical banded gastroplasty. The most common indication for rev-RYGB was symptomatic gastro-gastric fistula in both the open (44%) and the laparoscopic (75%) groups. Other indications included gastrojejunal obstruction, marginal ulcer, intractable reflux, roux limb obstruction, and large pouch size. Average time from the original procedure was 44 months in the laparoscopic group and 43 in the open group. Average operative time for the open group was 207 min and 261 min for the laparoscopic group (p>0.05). The average length of stay was 2.4 days in the laparoscopic group and 7.9 days in the open group (P=0.001). There was one intraoperative complication of a splenectomy in the open group and none in the laparoscopic group. There was one leak in the open rev-RYGB series, and no deaths in either group.

**Conclusion:** In this limited series, there was no difference between the two groups in patient demographics, operative time, or intra-operative or postoperative complications. The length of stay, however, was significantly lower in the laparoscopic group compared to the open group. This sug-
<figure><img src="image_79.png" /></figure>

# SAGES POSTER ABSTRACTS

gests that laparoscopic rev-RYGB, despite its technical complexity, may offer patients a faster recovery.

## Bariatric Surgery - P094

**USE OF 3M? TEGADERM? ABSORBENT CLEAR ACRYLIC DRESSING ON SURGICAL WOUNDS, Brian E Lahmann**
MD, Christopher D Joyce MD, Midwest Comprehensive Bariatrics, Joliet, IL

This study was an open-label, prospective, non-comparative evaluation of the use of a new transparent absorbent dressing on surgical incision wounds. The objective was to evaluate performance of the dressing for this use. Twenty patients that completed Open Gastric Bypass Surgery (OGBS, N=10) or Laparoscopic Gastric Bypass Surgery (LGBS, N=10) were studied. Incisions were closed with subcuticular sutures and 3M ? Steri-Strips? Wound Closure (LGBS group), or with staples (OGBS group). The dressing was applied over the closed incisions in the OR. Dressings were removed prior to discharge or by post-op day-3. Assessments of dressing performance were completed at application and at removal. Data was analyzed with descriptive statistics. There were 5 male and 15 female patients. Mean (SD) Age = 43.6 (10.7) years, Height = 65.6 (3.5) inches, Weight = 284.1 (72.3) lbs. Each LGBS patient had five small incisions (N=50) and each OGBS patient had one or two larger incisions (N=11). At application and removal of the dressings, the vast majority of clinician dressing assessments were rated as Good or Very Good. This included: ability to assess wound through the dressing (100% at application, 98% at removal), conformability (100%), application ease (100%), removal ease (100%), absorbency (98%), adhesion (97%), barrier properties (98%), comfort during removal (98%), overall comfort (100%), non-adherence to wound (100%), and wear-time (98%). There was little (12%) to no (88%) residue left on the skin, and there was little (2%) to no (98%) odor associated with the dressing or wound. Clinician assessments of the value on transparency was High to Very High in 98% of incisions, and overall satisfaction was rated as Good to Very Good in 97% of incisions. Complete approximation occurred in all incisions. **CONCLUSIONS:** The new transparent absorbent dressing performed well and may be an appropriate choice for dressing surgical incision wounds.

## Bariatric Surgery - P095

**USE OF A BLADED OPTICAL PERITONEAL ACCESS TROCAR IN THE UNINSUFFLATED ABDOMEN; A FIVE-YEAR EXPERIENCE, Timothy R Lapham MD, Michael Tarnoff MD, Julie Kim**
MD, Scott Shikora MD, Tufts- New England Medical Center

**Background:** The Visiport is a widely-used bladed optical access trocar that provides convenient, safe peritoneal entry. Although the device is typically used in an abdomen insuflated by closed technique, we have used it as our primary method of entry and insufflation. Although uncommon, injuries associated with abdominal access for laparoscopic surgery can be catastrophic. FDA reporting for injuries associated with the Visiport exists, but the system is voluntary and the rate of injury is unknown. Comprehensive long-term reviews looking at experience with use of this trocar in an uninsufflated abdomen are lacking. We present our 5-year experience.

**Methods:** From 7/30/2001 to 8/30/2006, laparoscopic access for all bariatric surgery at a single center was gained using the 5mm-12 mm Visiport device without prior insufflation. Three attending surgeons and five laparoscopic bariatric fellows used the device for a total of 1,626 cases, including 1,233 laparoscopic gastric bypass procedures (LGBP) and 393 laparoscopic adjustable gastric band placements (LAGB). All LAGB had an off-midline Visiport insertion. The LGBP entry point was midline except in cases where alternate site access was desired due to prior surgery.

**Results:** 1,623 of 1,626 (99.8%) entries were uneventful. Three injuries occurred (0.2%). Two required conversion to laparotomy and repair of lateral retroperitoneal bleeding. The other patient had self-limited retroperitoneal bleeding that was managed laparoscopically. All injuries occurred with placement of the trocar in an alternate site off the mid-

line. No injuries occurred with midline placement. There was no long-term morbidity and no mortality associated with the injuries.

**Conclusion:** Use of the Visiport without prior insufflation is safe in the morbidly obese population. It appears to be safest in the midline, where the layers of the abdominal wall are easily recognized. Alternate site entry requires extra caution because the anatomic layers are less predictable and harder to recognize.

## Bariatric Surgery - P096

**EFFECT OF BARIATRIC SURGERY ON WEIGHT LOSS IN PATIENTS WITH TYPE 2 DIABETES, Hongchan Lee**

MD, Leslie Tyrie MD, James J McGinty MD, Blandine Laferrère MD, Julio A Teixeira MD, Division of Bariatric Surgery, Department of Surgery, Division of Endocrinology Diabetes and Nutrition, St. Luke's-Roosevelt Hospital Center, Columbia University

**BACKGROUND:** Laparoscopic bariatric procedures, Roux-en-Y Gastric Bypass (LRYGBP) and Adjustable Gastric Banding (LAGB), are the most effective interventions resulting in sustained weight loss in morbid obese patients with co-morbid condition such as DM. Studies suggest that patients with diabetes do not respond to weight loss program as well as non-diabetic. Data show that LRYGBP induces more weight loss that LAGB, however, it is unclear whether this applies specifically to patients with diabetes.

**OBJECTIVE:** To study the weight loss in the 12 months after LRYGBP and LAGB in patients with type 2 diabetes.

**METHODS:** Chart of 136 patients seen who underwent LRYGBP and LAGB between 2001 and 2005 were reviewed and data collected on age, BMI, duration of DM, DM medications, and % EBWL at 1,3,6, and 12 months. 63 complete data were obtained (LRYGBP=43/116, LAGB=20/20). To compare between LRYGBP and LAGB, an unpaired Student t-test with covariant analysis was used for statistical analysis.

**RESULTS:** Results are expressed as mean±SD. Mean age was 45.4±10.6yr for LRYGBP versus 45.6±9.7yr for LAGB(p>0.01) and preoperative BMI was 52.5±9.2kg/m2 versus 43.25±4.6kg/m2,(p<0.001) respectively. Preoperative duration of DM was 6.4±6.4yr versus 3.5±3.2yr (p<0.001), and the global EBWL was 25.5% for LRYGBP versus 17.2% for LAGB at 1 month(p<0.001), 47.3% versus 27.2% at 3 months(p<0.001), 68.3% versus 32.8% at 6 months(p<0.001), 82.9% versus 40.9% at 12 months(p<0.001), respectively. The percentage of patients out of diabetes medications in 1 month were 65.1% for LRYGBP versus 20.0% for LAGB (p<0.001), 68.6% versus 22.5% in 3 months(p<0.001), 72.1% versus 25.0% in 6months(p<0.001), 95.4% versus 80.1% in 12 months (p<0.001).

**CONCLUSIONS:** Both weight loss procedures are effective in inducing significant weight loss and improving Type 2 DM. As in non-diabetic, LRYGBP is associated with significantly more weight loss than LAGB in patients with diabetes.

## Bariatric Surgery - P097

**LAPAROSCOPIC SLEEVE GASTRECTOMY AS AN ALTERNATIVE OPTION IN LOW BMI PATIENTS: INITIAL RESULTS, ANDREAS KIRIAKOPOULOS MD, DIMITRIOS TSAKAYANNIS MD, DIMITRIOS LINOS PhD,** 1st Surgical Clinic, Department of Surgery, ??Hygeia?? Hospital, Athens, Greece

**Objective:** Laparoscopic sleeve gastrectomy (LSG) has been used in high-risk super-obese patients or as a part of a two-stage procedure followed by Roux-en-Y gastric bypass (RYGBP) or duodenal switch (DS) in super-super obese patients. The aim of this study is to evaluate the efficacy of laparoscopic sleeve gastrectomy for morbidly obese patients with BMI<50

**Patients and Methods:** We have prospectively studied the initial eight patients that underwent laparoscopic sleeve gastrectomy. The operation was performed through one (or occasionally two) 12-mm ports and two 5-mm ports, using the Endo-GIA stapler to create a lesser curve gastric tube over a 32-Fr bougie. Study endpoints included operative time, complication rates, hospital length of stay and percentage of excess weight loss (% EWL).
<figure><img src="image_80.png" /></figure>

**Results:** There were three females and five males with mean age 40.5 yrs (range 28-50) and mean BMI 45.95 kg/m? (range 40.7-49.2). Mean operative time was 167.5 min (range 90-240). There were no intraoperative or postoperative complications and all patients discharged on the 2nd postoperative day after an upper GI series and onset of clear liquid diet. At a mean follow-up of 6.25 months the % EWL reached 46% ± 11.2, whereas the most noteworthy feature is the significant loss of appetite reported by all patients

**Conclusions:** Laparoscopic sleeve gastrectomy has been safe and also highly effective for weight reduction in our small series. It may constitute an acceptable surgical option for low BMI patients, although accrual of more patients and longer follow-up will be necessary to evaluate long-term results.

## Bariatric Surgery - P098

### EARLY RESULTS OF REMNANT GASTRECTOMY FOR GASTRO GASTRIC FISTULAE AFTER DIVIDED ROUX Y GASTRIC BYPASS FOR MORBID OBESITY, Emil Matei MD, Samuel Szomstein MD, Raul J Rosenthal MD, Cleveland Clinic Florida

**Background:** Gastro gastric fistula (GGF) is a rare complication of divided Roux-en-Y gastric bypass (RYGBP). The incidence of GGF in our experience is 1.2%. To our knowledge, there is no standardized surgical treatment option for this entity. We present a novel surgical approach that removes the gastric remnant avoiding dissection near the fistulous tract.

**Methods:** We retrospectively reviewed 606 consecutive patients who underwent divided RYGBP for morbid obesity at our institution. The diagnosis of GGF was made with upper endoscopy, gastrografin/barium swallow with supine and left lateral decubitus films or CT scan of the abdomen. The indications for surgery (remnant gastrectomy; RG) included pain, weight regain, bleeding and recurrent stricture.

**Results:** 25 patients were diagnosed with GGF (1.2%). 10 patients were treated medically and 15 surgically with remnant gastrectomy (RG). 11 of the 15 patients with RG had a RYGBP at out institution (73%). All 15 had an antecolic-ante-gastric divided RYGBP. 14 RG were performed laparoscopically (93%) while one was converted to an open procedure (7%). The mean hospital stay was 4.7 days. Morbidity in 5 patients (33%) was due to pneumonia, wound infection and bleeding. There were no mortalities. Follow up at 11 months showed weight loss in 93% of patients. There was a complete resolution of the pain, ulcer and GGF in 100% of the cases.

**Conclusions:** Remnant gastrectomy appears to be a safe and efficient surgical approach in the management of GGF.

## Bariatric Surgery - P099

### HORMONAL VALIDATION OF THE ROLE OF WEIGHT LOSS SURGERY IN THE TREATMENT OF POLYCYSTIC OVARIAN SYNDROME, C A McCloskey MD, S G Mattar MD, A P Courcoulas MD, G G Hamad MD, R Ramanathan MD, P R Schauer MD, M Wilson MD, G M Eid MD, University of Pittsburgh Medical Center and the VA Health Care System

**INTRODUCTION:** Obesity has been recognized as a major factor in the pathogenesis of polycystic ovarian syndrome (PCOS). In an earlier study, our group has demonstrated that the clinical manifestations of PCOS, significantly improved following surgical weight loss. The aim of the present study was to determine whether surgical weight loss is an effective treatment for PCOS, based on normalization of the hormonal and metabolic abnormalities associated with it.

**METHODS:** We performed a prospective analysis of women diagnosed with PCOS who underwent laparoscopic Roux en Y gastric bypass (LRYGBP) between January 2004 and June 2005. The diagnosis of PCOS was based on a total testosterone level >40 ng/dl and/or a free testosterone level >5.5 pg/ml, after excluding other causes of hyperandrogenism. Biochemical markers associated with PCOS, including cholesterol, triglycerides, insulin, and free testosterone, were drawn preoperatively and compared at 6 and 12 months

postoperatively.

**RESULTS:** A total of 14 women completed the study, 3 were lost to follow up. The mean age was 36.2. Mean preoperative BMI was 44.8 ± 1.6. All results are reported at 12 months postoperatively. The mean BMI decreased to 29.1 ± 1.6, with a mean excess weight loss of 66.5%. Total and free testosterone levels decreased from a preoperative mean of 59.0 ± 8.2 ng/dl and 5.9 ± 0.24 pg/ml, respectively, to a mean of 33.7 ± 4.4 ng/dl (p= 0.012) and 2.2 ± 0.26 pg/ml (p<0.001). Mean insulin levels decreased from 39.3 ± 6.9 mIU/ml preoperatively to 10.0 ± 3.2 mIU/ml (p < 0.001). Mean cholesterol levels decreased from 219 ± 14.9 mg/dl preoperatively to 160.9 ± 7.2 mg/dl (p<0.001). Mean triglyceride levels were 162.9 ± 17.8 mg/dl preoperatively compared to 71.8 ± 6.72 mg/dl (p<0.0001). Prior to weight loss, only four of 14 patients (28.5 %) reported regular menses. At follow up, all patients reported having regular menses.

**CONCLUSIONS:** In obese patients with PCOS, weight loss following LRYGBP results in normalization of biochemical parameters in parallel to the established clinical benefits. These data further support the influential roles of obesity and, in a converse manner, weight loss, on the human hormonal milieu.

## Bariatric Surgery - P100

### INCIDENCE AND MANAGEMENT OF GASTROJEJUNAL ANASTOMOTIC STENOSIS AFTER LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS USING A HAND-SEWN TECHNIQUE, Sandra Medina-Escobedo MD, Gaby A.

Alarcón-Jarsún MD, Miguel F. Herrera PhD, Francisco Fournier MD, Gonzalo Rodríguez MD, Sergio Cañedo MD, The Obesity Clinic. ABC Medical Center, México City, MEXICO.

**Introduction:** Gastrojejunal strictures are a well-documented complication of RYGBP with frequencies ranging from 3% to 35%. The aim of the present study is to analyze the incidence, presentation, and management of gastrojeuneal anastomotic strictures after LRYGBP using a hand-sewn gastrojejunostomy.

**Patients and Methods:** In an 18-mont period, 110 patients underwent LRYGBP. All gastrojejunostomies were hand-sewn in two layers using running sutures (3-0 Poliglicolic acid for the internal and 3-0 Silk for the external layer). A 32 French bougie was used to calibrate the anastomosis giving a final diameter close to 15mm. All patients were followed for a minimum of 6 months. In the presence of dysphagia, food intolerance or vomit, an upper endoscopy was performed. Stenosis was diagnosed when a 9mm diameter endoscope would not pass through the gastroenterostomy without dilatation. Demographics, symptoms, time of occurrence, management, and outcome of patients presenting with stricture of the gastrojejunostomy were analyzed.

**Results:** A total of 5 patients developed stricture of the gastrojejunostomy (4.5%). There were 3 females and two males, with a mean age of 40.2 years (range 28-54). BMI before surgery was of 41.1 Kg/m2 (range 36-50). Four patients complained of dysphagia. Postprandial pain was present in 3 patients. One patient also presented vomit. Mean time between surgery and the diagnosis of gastrojeuneal stenosis was 3 months (range 1-7). Mean size of the stenosis was 7-9mm. Pneumatic endoscopic dilation to 15-18mm was performed to all patients. Stenosis resolved in all 5 patients after dilation. In a follow-up period of 8 months, none of the patients has experienced recurrence of the stenosis.

**Conclusions:** Construction of a small (~15mm) gastrojejunostomy using a hand-sewn technique has resulted in a very low rate of gastrojeunal stenosis (4.5%). One pneumatic endoscopic dilation to 15-18mm achieved definitive treatment of the stenosis in all 5 patients.
<figure><img src="image_81.png" /></figure>

# SAGES POSTER ABSTRACTS

## Bariatric Surgery - P101

**A 10-YEAR EXPERIENCE WITH LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING FOR MORBID OBESITY,**
Reinhard MITTERMAIR MD,S. Obermueller MD,F. Aigner MD,H. Nehoda MD, Department of Surgery, University Hospital Innsbruck, Medical University Innsbruck, Austria

**INTRODUCTION:** Because of its encouraging early results regarding weight loss and morbidity, laparoscopic adjustable gastric banding (LAGB) has been considered by many as the treatment of choice for morbid obesity. The aim of this study was to assess our 10-years results with the Swedish adjustable gastric banding.

**METHODS AND PROCEDURES:** Between January 1996 and December 2005 we performed 949 bariatric procedures and therefrom 775 patients underwent LAGB. All data (demon- graphic and morphologic, co-morbidities, operative, and fol- low-up) were prospectively collected in a computerized databank.

**RESULTS:** 21 different surgeons (4 bariatric and 17 general surgeons) performed LAGB. There was no mortality or pul- monary embolism. Average total weight loss was 27.4 kg after 1 year, reaching an average total of 42.7 kg after 8 years. Mean excess weight loss was 44% after 1 year and 64% after 8 years, and the BMI decreased from 46.7 to 28.1 kg/m2. Complications requiring reoperation occurred in 9.2%. In super-obese patients (BMI > 50 kg/m2) complication rate was 26.7%.

**CONCLUSION:** LAGB is an effective and safe procedure for the surgical treatment of morbid obesity. Because of the high complication rate super-obese patients should only be treated by experienced bariatric surgeons.

## Bariatric Surgery - P102

**MATCHED PAIR ANALYSIS OF PROXIMAL VS. DISTAL LAPAROSCOPIC GASTRIC BYPASS WITH 4 YEARS FOLLOW- UP,**
Markus K Müller MD,Susanne Räder MD,Stefan Wildi MD,Dieter Hahnloser MD,Pierre-Alain Clavien MD, Markus Weber MD, Department for Visceral & Transplant Surgery; University Hospital Zurich, Switzerland

**Objective:** To define whether proximal or distal laparoscopic gastric bypass represents the better approach to treat patients with morbid obesity.

**Background:** While most surgeons perform a proximal gas- tric bypass with a Roux limb length of 150cm, others have suggested that a longer Roux limb may offer superior weight loss. In a distal gastric bypass the distance from the Roux en-Y anastomosis to the ileocaecal valve is fixed at 150 cm.

**Method:** A matched pair design using a large prospectively collected database of 402 laparoscopic gastric bypass proce- dures since 2000 was used. All patients were operated by two surgeons. A total of 25 patients with a primary distal gastric bypass were randomly matched one by one with 25 patients with a primary proximal gastric bypass according to age, gender and preoperative body-mass-index (BMI).

**Results:** Demographic data as well as preoperative BMI and comorbidities were comparable in both groups reflecting an adequate matching.

**Feasibility and safety:** All distal gastric bypass operations were performed laparoscopically; one proximal gastric bypass procedure had to be converted to open surgery. Mean operating time was 170 min for proximal and 242 min for distal gastric bypasses (p=0.004). Median hospital stay was 8 days (R: 4-43 d.) for the proximal and 9 days (R: 6-24 d.) for the distal bypass. There was no mortality in both groups. The incidence of overall complications was 52% vs. 64% (p=0.2). Complications: wound infections were noted in 16% of patients in the proximal vs. 32% in the distal group. There was a trend for less late small bowel obstruction due to internal herniation in the proximal gastric bypass group, 8% vs. 20% respectively(p=0.21). Additionally, one patient in the distal gastric bypass group had to be converted to a proximal gastric bypass for severe protein deficiency.

**Efficiency:** Both groups were comparable in terms of weight loss during the 4 year follow up with no significant differ- ence at any time point. Body mass index decreased at 4

years from 45.9kg/m2 to 31.73 in the proximal group and from 45.8kg/m2 to 33.11 in the distal group. There was no difference in the prevalence of diabetes, arterial hyperten- sion and dyslipidaemia preoperatively as well as in the fol- low up.

**Conclusion:** Proximal or distal laparoscopic gastric bypass are feasible and safe. The distal gastric bypass offers no advantage for weight loss and reduction of co-morbidities.

## P103 - Withdrawn

## Bariatric Surgery - P104

**ENDOSCOPIC FINDINGS IN MORBID OBESE PATIENTS UNDERGOING BARIATRIC SURGERY,**
Rodrigo Muñoz MD,Camilo Boza MD,Alex Escalona MD,Enrique Norero MD,Maria Jose Contardo,Carolina Valdebenito MD,Francisco Zuñiga MD,Luis Ibañez MD, Department of Digestive Surgery. Pontificia Universidad Católica de Chile

**INTRODUCTION** - Routine upper endoscopy is not consid- ered in many bariatric programs before surgery. The aim of this study was to determine abnormal endoscopic findings and risk factors for altered upper endoscopy in preoperative evaluation. PATIENTS AND METHODS- Upper endoscopy reports were analyzed in patients undergoing gastric bypass between February, 1999 and June, 2006. Univariate and multivariate logistic regression were performed to identify risk factors.

**RESULTS-** 626 patients were evaluated with upper endoscopy prior to bariatric surgery, 452 women (72%) and 174 (28%), age and preoperative BMI was 42 ± 6,5 kg/m2 and 38,5 ± 11 years respectively. An abnormal endoscopy was identified in 288 (46%) patients. Age of patients with abnormal and normal endoscopy was 40 ± 11 and 36,8 ± 11 years respectively (p<0,001). The most common findings were: gastritis 21%, esophagitis 16%, hiatal hernia 10,7%, duodenitis 7,8%, gastric ulcers 2,7%, duodenal ulcers 2,6%, gastric polyps 1,3%, barret's esophagus 0,16% and gastric cancer 0,16%. Univariate and multivariate analysis showed that age is a independent risk factor for abnormal endoscopy (odds ratio = 1,03; 95% confidence interval, 1,02-1,05).

**CONCLUSIONS-** routine preoperative upper endoscopy before bariatric surgery is important in this population for diagnosis and treatment of gastroesophageal disease. Preoperative age was the only independent risk factor for abnormal endoscopy.

## Bariatric Surgery - P105

**DRAINS AND UPPER GIS AFTER GASTRIC BYPASS SURGERY? ARE THEY NECESSARY?,**
Nissin C Nahmias MD,Dallal Ramsey MD, Department of Surgery, Albert Einstein Healthcare Network, Philadelphia PA

**Introduction:** Serious complications after gastric bypass sur- gery can be diagnosed by clinical indicators alone. The rou- tine use of drains and upper GI series (UGI) has been advo- cated to aid in the diagnosis and management of gastrojeju- nal leak after gastric bypass as well as diagnose intraab- dominal bleeding.

**Methods and procedures:** 300 consecutive primary laparo- scopic gastric bypass procedures were performed by a sin- gle surgeon without the use of routine drains or post-opera- tive upper GI series. All patients were entered prospectively in our database.

**Results:** There were no adverse events or delays in diagno- sis related the lack of routine drains or UGI usage. At the surgeon's discretion, three patients (1.0%) did have a drain placed at the time of surgery due to a particularly difficult gastrojejunal anastomosis - none developed anastomotic leak. Upper GI series were ordered post-operatively in five patients all for unexplained tachycardia, none of who had abnormal radiographic findings. Three of these patients underwent diagnostic laparoscopy. Only one patient had a leak, which was identified on post-operative day 1 from the gastrojejunal anastomosis. Four patients had clinical signs of a complete GJ obstruction. Two resolved completely within 48 hours, and two patients required endoscopic inter- vention without the need for UGI. Six patients required a
blood transfusion; all of who developed tachycardia and five were from bleeding in the GI tract.

**Conclusions:** Routine use of drains and UGI series were not necessary for the safe management of gastric bypass patient in our series. Clinical indicators for leak, obstruction or bleeding were obvious without the additional and sometimes confounding data from UGIs or drains.

## Bariatric Surgery - P106

### COMPARISON OF THREE DIFFERENT GASTROJEJUNOSTOMY ANASTOMOSIS TECHNIQUES IN LAPAROSCOPIC ROUX EN Y GASTRIC BYPASS (LRYGBP) SURGERY, Surya Prasad M Nalamati MD,Venkata Bodavula MD,Stephanie Seiki BS,Laura Choi MD,Keith Zuccala MD,Leonard Maffucci MD,Madhu Rangraj MD, Departments of Surgery Sound Shore Medical Center Of Westchester, New Rochelle, NY and Danbury Hospital, Danbury, CT.

**Introduction:** The most important step in the laparoscopic Roux-en-Y gastric bypass (LRYGBP) is the creation of the gastro-jejunostomy. Three different techniques are commonly used to perform this anastomosis at our institutions. They are 1. EEA Stapled anastomosis (ESA), 2. Linear staple Anastomosis (LSA), 3. Hand sewn anastomosis with Endostitch device (HSA). We compared the three techniques in terms of operative time, intra operative, early and late complications(bleeding, perforation, leak, wound infection, ulcer, stricture, others).

**Methods:** We retrospectively analyzed the prospectively maintained bariatric surgery database of four surgeons performing LGBP using the three techniques and compared all the patients undergoing LRYGBP at two hospitals from Dec 2004 to Aug 2006.

**Results:** 312 procedures were done (n=312) during this period, ESA-100, HSA-102, LSA-110. The mean operative time for ESA was 165, LSA was 128 and HSA was 115 minutes respectively. Overall complications rate in ESA was 12%(n=12), LSA was 11.8%(n=12) and HSA was 12.7%(n=14). Hemorrhage rate in ESA was 2%(n=2), LSA 1.8%(n=2), and HSA 2.9%(n=3). Stenosis rate in ESA was 3%(n=3), LSA 0.9%(n=1) and HSA being 1%(n=1). Anastomotic leaks in ESA were 1%(n=1), LSA 0.9%(n=1), and HSA 1%(n=1). Intestinal perforation in LSA was 1.8%(n=2) and HSA was 1%(n=1). Wound infections in ESA were 6%, LSA 1%, and HSA 0%. Mortality in all three groups was 0%.

**Conclusion:** HSA technique has lesser operative time when compared to ESA and LSA techniques. Wound infection rate using ESA technique appears to be higher than the other two techniques. Use of a wound protection device is recommended to minimize infections. Other complication rates between ESA, LSA and HSA groups are comparable despite the differences in technique. There was no mortality noted in all the three groups. Overall major complication rates (hemorrhage, leaks, stenosis) in LRYGBP using all the three different G-J anastomotic techniques at our institutions have been low and comparable to Nationally published data.

## Bariatric Surgery - P107

### A NOVEL TREATMENT APPROACH FOR POSTPRANDIAL HYPOGLYCEMIA AFTER ROUX-EN-Y GASTRIC BYPASS, Richard Nguyen DO,William O Richards MD, Vanderbilt University

**Introduction:** In this case report we present a novel approach to patient who presented 2 years status post Roux-en-Y gastric bypass surgery with unexplained postprandial hypoglycemia. Postprandial hypoglycemia after Roux-en-Y gastric bypass surgery has previously been described. A theory that hypoglycemia post gastric bypass was thought at one time to be related to Nesidioblasotsis but now that theory is in real question as pathology specimens could not be confirmed.

**Methods:** The patient's initial symptoms were characteristic of dumping syndrome, with vasomotor symptoms of diaphoresis, weakness, dizziness, and flushing, however she also presented with hypoglycemia with documented accuchecks of 40s-50s. We theorized that this patient presented

with late dumping syndrome with concomitant reactive hypoglycemia. The pt was treated with a laparoscopic revision of her gastrojejunostomy to narrow the outlet.

**Results:** The procedure was performed laparoscopically with operating ports placed in a fashion similar to our technique for a gastric bypass procedure. Upon examination of the abdomen an intraoperative endoscopy was performed to confirm the location of the gastrojejunostomy intra-abdominally. The gastrojejunostomy was measured to be >30 mm in diameter. We then used a technique that can be best described as a reverse Heincke-micliwiez pyloroplasty to narrow the lumen. Once this was complete the gastrojejunostomy was narrowed to a size of <10mm.

**Conclusions:** This procedure has resulted in a delayed gastric emptying of her gastric pouch as well as an immediate and complete resolution of her reactive hypoglycemia. We submit this as a novel approach and treatment to hypoglycemia after Roux-en-Y gastric bypass.

## Bariatric Surgery - P108

### WOUND PROTECTOR DEVICE DECREASES PORT SITE INFECTION AFTER LAPAROSCOPIC ROUX EN Y GASTRIC BYPASS, John R Pender MD,Michael J Barker MD,Walter J Pories MD,Willaim H Chapman MD, Division of Bariatric Surgery/Minimally Invasive Surgery, Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, North Carolina

**Introduction:** Wound infections are one of the most frequent complications of the laparoscopic roux en y gastric bypass (LRYGB) procedure. In an effort to reduce the rate of this complication, various techniques have been used. It was hypothesized that routine use of a wound retractor system would reduce this complication.

**Methods:** A 2.5 cm Alexis® Wound Retractor System (Applied Medical, Rancho Santa Margarita, CA) was used in the 15mm port site of 25 consecutive patients. Retrospectively, the previous 25 LRYGB procedures that were performed without a wound retractor system were examined. The two groups were similar in age, comorbidities, and body mass index. A comparison of infection rates between the two groups was then examined. Statistical analysis was performed.

**Results:** 5 patients developed wound infections at the 15mm port site in the non-protected group. There were no infections at the 15mm port site in the patients where the device was used. These results were found to be significantly significant with a P value of < 0.02.

**Conclusion:** Routine use of a wound retractor system in the 15mm port site reduces wound infection rates after laparoscopic roux en y gastric bypass.

## Bariatric Surgery - P109

### BARIATRIC SURGERY IN THE PRESENCE OF INTESTINAL MALROTATION: EXPERIENCE WITH THE DUODENAL SWITCH., R Sudan MD, V Puri MD, A Silver MD, A J Wright MD, B F Murray MD, Creighton University Medical Center, Omaha, NE

**Introduction:** About 102,000 bariatric procedures are performed annually in the US. The incidence of intestinal malrotation (IM) is 1 in 500 & may pose technical problems during bariatric procedures.

**Methods:** Retrospective review of record of bariatric procedures using IM as keyword. Individual cases were reviewed.

**Results:** 3 patients with IM underwent 4 bariatric procedures at Creighton University from 2002-6. The cases are summarized.

#1 - A 50 yr old female with BMI 50 was taken up for open duodenal switch (DS) & intraoperatively found to have IM. Meticulous dissection clearly defined the anatomy. Appendectomy was performed as routine. The normal orientation of alimentary limb(AL) (to the right side) & bilipancreatic limb (BPL) (to the left side) (Fig) needed to be reversed. The AL was brought up in retrocolic fashion for a tension-free duodeno-enteral anastomosis & the small bowel was placed in the right abdomen & large bowel in left abdomen following principles of the Ladd procedure. The

<figure><img src="image_82.png" /></figure>
<figure><img src="image_83.png" /></figure>

# SAGES POSTER ABSTRACTS

patient is doing well at 3 yrs followup(FU).

#2 - A 51yr old male with BMI 60 was taken for laparoscopic gastric bypass & intraoperatively found to have IM. An enteroenterostomy was performed but the roux limb could not reach the stomach safely without tension. The stomach was left undivided & the procedure terminated. At an open operation 6wks later, the enteroenterostomy was reversed & an open DS performed uneventfully as for patient 1. He is doing well at 9 months FU.

#3 - A 58 yr old male with BMI 48 & known IM elected to undergo bariatric surgery. Based upon our experience, robotic DS (65 patients) & DS in IM (2 patients), we performed a laparoscopic/robotic DS uneventfully. He is doing well at 6 months FU.

**Conclusion** - Open/laparoscopic/robotic DS can be safely performed in IM. Key anatomic principles; meticulous dissection, reversing the orientation of AL & BPL, retrocolic passage of AL, tension free duodeno-enterostomy, appendectomy & following principles of the Ladd operation are important

## Bariatric Surgery - P110

### THROMBO-EMBOLIC RISKS OF MORBIDLY OBESE PATIENTS UNDERGOING A LAPAROSCOPIC GASTRIC BYPASS WITH ROUX Y LIMB, Philippe J Quilici

MD, Alexander S Tovar MD, Carie McVay MD, Providence Saint Joseph Medical Center and Cedars Sinai Medical Center

A retrospective analysis of 1314 morbidly obese patients who consecutively underwent a standard laparoscopic gastric bypass with Roux Y limb [LGBRY] by an experienced, surgical team was conducted to assess their thromboembolic risks.

All surgical candidates were selected using NIH and SAGES guidelines. Non ambulatory patients were excluded. All patients underwent a routine DVT-PE prophylaxis which included pneumatic stockings, intra and post-operative 5000 Units of sub-cutaneous heparin every eight hours and an aggressive, mandatory pre and post-operative ambulatory protocol.

The age range of the patients was 15 to 71 years old. Mean BMI was 44.4, mean operative time was 58 minutes and mean hospital stay was 2.6 days. 218 patients did not receive routine heparin prophylaxis for various reasons. Two temporary vena cava filters were placed. No deep venous vein thromboses were noted. Two severe thromboembolic events were reported: one non lethal pulmonary embolus and one mesenteric ischemia in two patients with undiagnosed genetic, hyper-coagulable states.

This analysis demonstrates the thrombo-embolic risks for patients undergoing LGBRY is lower than previously reported in high volume bariatric centers and can be dramatically reduced with an aggressive pre and post-operative ambulation protocol.

## Bariatric Surgery - P111

### THE UTILITY OF ROUTINE POSTOPERATIVE UPPER GI SERIES FOLLOWING GASTRIC BYPASS Asok Doraiswamy

MD, Jason J Rasmussen MD, Jonathan Pierce MD, William Fuller MD, Mohamed R Ali MD, UC Davis Medical Center

**Background:** Routine UGI studies following laparoscopic Roux-en-Y gastric bypass (LRYGBP) has the potential advantage of early identification of anastomotic complications.

The aim of our study was to evaluate the efficacy of routine post-operative UGI and its relation to clinical outcomes.

**Methods:** Over a three year period, 516 patients underwent LRYGBP followed by routine post-operative UGI studies. Data were collected regarding the results of the UGI, clinical parameters, and patient outcomes. Study groups were composed of patients with a normal UGI (Group I, n=455), abnormal UGI not requiring further intervention (Group II, n=36), and abnormal UGI requiring further intervention (Group III, n=25). Statistical significance was set at alpha=0.05 level for all analyses.

Results: The three study groups were not statistically different in mean age (42) or BMI (45) and were predominantly female (90%). Most patients (95%) had an uneventful post-operative course (Groups I & II). Anastomotic complications

(GJ & JJ) were uncommon (1.3%). The sensitivity of the UGI for anastomotic leak in this study was low (33%). However, all patients with alimentary limb obstruction (n=3) had UGI evidence of this complication. Of the 516 UGI reports, there were only 25 (4.8%, Group III) which were abnormal and required some form of intervention ranging from serial imaging (84%) to re-operation (16%). Of the various clinical parameters examined (Table 1), the patients in Group III demonstrated a significantly higher prevalence of fever (p<0.001), tachycardia (p<0.01), vomiting (p<0.001), and POD1 leukocytosis (p<0.005).

<table><thead><tr><th></th><th>Group I (n=455)</th><th>Group II (n=36)</th><th>Group III (n=25)</th></tr></thead><tbody><tr><td>Fever (T>36.5)</td><td>36 (8%)</td><td>2 (5.5%)</td><td>8 (32%)</td></tr><tr><td>Tachy(P>100)</td><td>98 (22%)</td><td>8 (22%)</td><td>12 (48%)</td></tr><tr><td>Tachy(P>110)</td><td>58 (12.7%)</td><td>5 (14%)</td><td>10 (40%)</td></tr><tr><td>Tachy(P>120)</td><td>13 (2.8%)</td><td>1 (2.7%)</td><td>5 (20%)</td></tr><tr><td>Hypotension</td><td>6 (1.3%)</td><td>5 (14%)</td><td>0 (0%)</td></tr><tr><td>Nausea</td><td>199 (43.7%)</td><td>19 (53%)</td><td>15 (60%)</td></tr><tr><td>Vomiting</td><td>10 (2.2%)</td><td>4 (11%)</td><td>5 (20%)</td></tr><tr><td>Fluid Balance(&gt;2L+)</td><td>50 (11%)</td><td>7 (19%)</td><td>2 (8%)</td></tr><tr><td>Fluid Balance(&gt;3L+)</td><td>14 (3%)</td><td>3 (8.3%)</td><td>1 (4%)</td></tr><tr><td>Leukocytosis POD 0</td><td>402 (88%)</td><td>29 (81%)</td><td>21 (84%)</td></tr><tr><td>Leukocytosis POD1</td><td>57 (12.5%)</td><td>10 (28%)</td><td>9 (36%)</td></tr></tbody></table>

**Conclusion:** Our data suggest that routine UGI after LRYGBP has limited utility as it may result in unnecessary intervention based on false positive results or a delay in treatment based on false negative results. We advocate selective UGI imaging following LRYGBP based on the patient's clinical factors, particularly fever and tachycardia.

## Bariatric Surgery - P112

### MARGINAL ULCERATION AFTER LAPAROSCOPIC GASTRIC BYPASS: AN ANALYSIS OF PREDISPOSING FACTORS IN 260 PATIENTS. Jason J Rasmussen MD, William Fuller MD, Mohamed Ali MD, UC Davis Medical Center

**Background:** Marginal ulceration (MU) after Roux-en-Y gastric bypass (RYGB) is diagnosed in 1-16% of patients. The factors predisposing patients to MU are still unclear.

**Methods:** A total of 260 patients who underwent laparoscopic RYGB were retrospectively reviewed. Data regarding demographics, comorbidities, BMI, H. pylori infection, gastrojejunal (GJ) anastomotic leaks, post operative bleeding, operative time, type of suture material and marginal ulcer formation were collected. Fisher's exact test was used to statistically analyze discrete variables and the student's t-test was used for continuous variables. Statistical significance was set at alpha =0.05.

**Results:** The overall MU rate was 7%. The various factors hypothesized to affect MU following laparoscopic RYGB are detailed in Table 1. Demographic data (age, gender distribution, BMI) did not differ significantly between patients who developed MU and those who did not (p >0.05). Similarly technical factors (choice of permanent or absorbable suture for the GJ anastomosis, attending as primary surgeon, robotic GJ, operative time, and post-operative hematocrit drop) were not statistically different between the two groups (p >0.05). Finally, the prevalence of comorbidities (diabetes, hypertension, obstructive sleep apnea, musculoskeletal complaints, dislipidemia, GERD and PUD) did not differ significantly between the two groups (p >0.05). However, preoperative H. pylori infection, that was adequately treated, was twice as common among the patients who developed MU compared to those who did not, 32% vs. 12% respectively (p = 0.02). All patients who developed MU had complete resolution of symptoms with PPIs and sucralfate. No reoperations were required for MU.

**Conclusion:** H. pylori may potentiate marginal ulcer formation. We hypothesize that H. pylori damages the mucosal barrier in a way that persists post operatively which may precipitate MU even when the organism was medically eradicated.
SAGES POSTER ABSTRACTS

<table><thead><tr><th></th><th>No MU</th><th>MU</th><th>P</th><th></th><th>No MU</th><th>MU</th><th>P</th></tr></thead><tbody><tr><td>Age</td><td>42</td><td>40</td><td>NS</td><td>PUD</td><td>39</td><td>0%</td><td>NS</td></tr><tr><td>% Male</td><td>10%</td><td>11%</td><td>NS</td><td>H. pylori</td><td>12%</td><td>32%</td><td>0.02</td></tr><tr><td>BMI</td><td>44</td><td>45</td><td>NS</td><td>Permanent suture</td><td>53%</td><td>47%</td><td>NS</td></tr><tr><td>Diabetes</td><td>23%</td><td>16%</td><td>NS</td><td>Absorbable suture</td><td>47%</td><td>53%</td><td>NS</td></tr><tr><td>Hypertension</td><td>49%</td><td>37%</td><td>NS</td><td>Attending Primary</td><td>22%</td><td>11%</td><td>NS</td></tr><tr><td>Sleep Apnea</td><td>50%</td><td>37%</td><td>NS</td><td>Robotic</td><td>22%</td><td>5%</td><td>NS</td></tr><tr><td>Musculoskeletal</td><td>79%</td><td>74%</td><td>NS</td><td>OR time (min)</td><td>17%</td><td>17%</td><td>NS</td></tr><tr><td>Dyslipidemia</td><td>42%</td><td>37%</td><td>NS</td><td>Intrapump Leak</td><td>8%</td><td>16%</td><td>NS</td></tr><tr><td>GERD</td><td>43%</td><td>53%</td><td>NS</td><td>Hct drop</td><td>7%</td><td>5%</td><td>NS</td></tr></tbody></table>

## Bariatric Surgery - P113

INTERNAL HERNIAS AFTER LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS ARE PREVENTED WITH BIOABSORBABLE SEAMGUARD® MATERIAL, MT ALLEMANG BS, DB RENTON MD, V K NARULA MD, KE HINSHAW BS, KM REAVIS MD, BJ NEEDLEMAN MD, WS MELVIN MD, DJ MIKAMI MD, THE OHIO STATE UNIVERSITY DEPARTMENT OF SURGERY, CENTER FOR MINIMALLY INVASIVE SURGERY

**Background:** Internal hernias are an important and common complication following RNYGB. The two potential spaces that internal hernias can occur are the jejunostomy mesenteric defect and the retro Roux limb space. The jejunostomy is usually closed with a running stitch; however the retro Roux limb space remains a common potential space for hernias. We hypothesize that substantial tissue bonding will prevent a Peterson's hernia by utilizing Gore Bioabsorbable SEAMGUARD® Material (BSG) on the mesentery staple line of the jejunum during creation of a Roux limb. We evaluated the BSG as a preventative measure for the development of these hernias in post-op laparoscopic gastric bypass patients.

**Methods:** We have prospectively followed 417 patients undergoing roux-en-Y gastric bypass since February 2005. Patients are routinely followed in clinic and we have performed all necessary re-operations since then.

**Results:** We have seen no internal hernias from the retro Roux limb space in the 417 patients where BSG was used on the mesentery staple line of the jejunum. A single patient who underwent laparoscopic gastric bypass with BSG on the small bowel mesentery developed a port site hernia on POD #37. This patient was taken to the operating room for laparoscopic repair of her port site hernia and abdominal exploration. During the hernia repair, we explored the retro Roux limb space where the BSG was previously applied. We could not separate the Roux limb from the transverse colon or transverse mesocolon where there was contact with the BSG.

**Conclusion:** BSG may be a possible way to prevent retro Roux hernias in patients undergoing laparoscopic Roux-en-Y gastric bypass. An animal study is currently being conducted to evaluate the tissue bonding between the BSG applied to the small bowel mesentery and the mesocolon.

## Bariatric Surgery - P114

ANTI-XA LEVELS OF TWO PROPHYLACTIC DOSING REGIMENS OF LOW MOLECULAR WEIGHT HEPARIN DURING LAPAROSCOPIC BARIATRIC SURGERY, BREA O ROWAN, DAVID A KUHL, MARILYN D LEE, DAVID S TICHANSKY MD, ATUL K MADAN MD, UNIVERSITY OF TENNESSEE HEALTH SCIENCE CENTER AND REGIONAL MEDICAL CENTER AT MEMPHIS

**Introduction:** Prophylactic anticoagulation is important during laparoscopic bariatric surgery. The correct dose for low molecular weight heparin, specifically enoxaparin, in the morbidly obese is not known. We investigated anti-Xa levels in laparoscopic bariatric surgery patients utilizing two different regimens of prophylaxis. Our hypothesis was that a higher dose of enoxaparin is needed to obtain appropriate anti-Xa levels.

**Methods:** Laparoscopic bariatric surgery patients were included in this study. The study was divided into two consecutive phases: Phase 1 (dose of 30 mg Q 12) and Phase 2 (dose of 40 mg Q12). Anti-Xa levels were drawn 4 hours after 1st and 3rd dose.

**Results:** There were 19 patients in Phase 1 and 33 patients in Phase 2. No differences in weight, height, body mass index, and gender were noted between both groups. Phase 1 patients had lower anti-Xa levels after both 1st and 3rd

dose compared to Phase 2 patients (0.06 vs. 0.14; p<0.05 and 0.08 vs. 0.15; p<0.05; respectively). More patients in Phase 2 had appropriate anti-Xa levels for prophylaxis (0.18 - 0.44) than Phase 1 after both 1st and 3rd dose (31% vs. 0%; p<0.02 and 42% vs. 9%; p=0.10 respectively).

**Conclusions:** Most patients did not have appropriate levels of anti-Xa even at the 40 mg Q12 dose. The lower dose (30 mg Q12) is too low for a majority of morbidly obese patients. Further studies need to examine the safety and efficacy of higher doses of enoxaparin.

## Bariatric Surgery - P115

LONG TERM OUTCOME OF LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING IN PATIENTS WITH ESOPHAGEAL DYSMOTILITY, JAYARAJ SALIMATH MD, SAMUEL SZOMSTEIN MD, RAUL ROSenthal MD, CLEVELAND CLINIC FLORIDA, WESTON, FLORIDA
The prevalence of GERD, esophageal manometric abnormalities, and nutcracker esophagus are high among the morbidly obese. Laparoscopic adjustable gastric banding (LAGB) has proven long-term weight loss with low morbidity. This study evaluates the clinical outcome of LAGB in patients with esophageal dysmotility on esophageal manometry.

**Methods:** 100 patients underwent esophageal manometry as a preoperative evaluation for LAGB. A single reviewer evaluated all manometric tracings. Patients with esophageal dysmotility were identified and their charts were retrospectively reviewed. Clinical and telephone interviews were conducted on patients who underwent LAGB. Results: Out of the 100 patients who underwent esophageal manometry between 2003 and 2004, we identified 24 (24%) patients with esophageal dysmotility. 13 (54.1%) patients underwent LAGB, 3 (12.5%) had laparoscopic Roux-en-Y gastric bypass (LRYGB), and 8 (33%) had not undergone any surgery. Of the 13 patients who underwent LAGB, 11 patients were contacted while 2 could not be reached. One patient had band removal after one year and underwent LRYGB due to poor weight loss. In the other 10, average weight loss was 47.5lbs (range 10 - 129lbs) with an average 3.1 band adjustments (range 1-6).

**Conclusion:** Postoperative emesis and GERD are the most common complaints in patients with abnormal manometric findings. In our study, patients who did not suffer from GERD preoperatively developed reflux symptoms approximately one to two years after band placement. Patients with the least amount of weight loss attributed their poor results to the fact that they could not to undergo afford band adjustments.

## Bariatric Surgery - P116

UTILIZATION OF THE INTRAGASTRIC BALLOON (BIB) IN PRE-OPERATIVE PREPARATION FOR SUPER OBESE PATIENTS WITH HIGH SURGICAL RISK COMPARING WITH TWO STEPS SURGERY, JOSÉ A SALLET, JOÃO C MARCHESINI MD, MAURÉLIO R RIBEIRO MD, JOSÉ A SALLET, JOÃO C MARCHESINI, MAURÉLIO R RIBEIRO JR., CARLOS E PIZANI, KEILA KOMOTO, PAULO C SALLET, ROBERTO TUSSI

**Background:** Superobese patients show a high surgical risk (major complications in 30% and mortality rate of 5-12%). The present study evaluates the use of BIB as a preoperative procedure aiming an initial weight loss and reduction of surgical risk.

**Methods:** From November 2000 to February 2003, 24 superobese patients (mean BMI= 60.3 ± 10.1 kg/m?) were treated with the BIB for at least four months before surgical treatment: 19 male (BMI= 59.0 ± 9.6) and 5 female patients (BMI= 65.3 ± 11.7). They showed associated diseases, including systemic arterial hypertension (13 cases), diabetes mellitus (5 cases), sleep apnea (10 cases), hypercholesterolemy (5 cases) and osteoarthrosis (8 cases).

**Results:** Patients showed mean percent excess weight loss (%EWL) of 23.4 ± 11.0%, mean percent total weight loss (%TWL) of 13.6 ± 6.5%, and mean BMI reduction of 8.4 ± 4.9 Kg/m?. More than 80% of patients showed improvement in hypertension and diabetes mellitus, with sleep apnea changed from severe to minimal. Surgical risk was reduced from ASA III-IV (before the BIB) to ASA II. All these patients were submmitted to bariatric surgery (GB, LAGB or BPD).

<figure><img src="image_84.png" /></figure>
<figure><img src="image_85.png" /></figure>

# SAGES POSTER ABSTRACTS

Two patients had wound infection (8.3%). There was no mortality.

**Conclusions:** Our results showed that the intragastric balloon is an effective technique in order to prepare super-obese patients in preoperative time, reducing the two steps surgery in super obese patients in more than 75 % and their major complications and mortality.

## Bariatric Surgery - P117

LAPAROSCOPIC ROUX-EN-Y GASTRIC BY PASS WITH DISTAL JEJUNUN-ILEAL DIVERSION - TECHINIQUE AND RESULTS, José A Sallet MD,Carlos E Pizani MD,Fábio L Bonaldi MD, José A. Sallet, Carlos E. Pizani, Fábio L. Bonaldi, Roberto Tussi, Jeovana Leal, Paulo C. Sallet.

**Background:** During november 98 to april 2005 we performed 2560 bariatric procedures that including: 21% Lap-Band, 49% Gastric By Pass, 26% BIB and 4% BPD (Duodenal Switch). The choice of the method was defined by protocols developed into a multidisplinary team, considering BMI, psychological and eating profile, surgery risk, agreement to physical activity and patients expectation.

**Methods:** In the first two years, we performed Gastric By Pass with Ring in 180 cases with 85% of excess weight loss after two years. We perceived with this kind of surgery the patients had too much difficult with solid foods. Therefore we decided to perform the surgery without ring. There was 274 cases with 69% of excess weight loss in two years and better eating quality.

**Thecnique:** In the last four years we began to perform Laparoscopic Roux-en-Y Gastric By Pass with a Distal Jejunun-Ileal Diversion distant about 1,5 to 2,0m from ileo-cecal valve. The surgery is all performed in a supra-meso-colic abdominal area. The gastroenteroanastomosis is always pre- gastric and precolic performed with linear stappler and we first make the enteroenteroanastomosis an than devide the intestine. So that, we cant test the both anasto-mosis with metilene blue.

**Results and Conclusion:** We had done 595 cases using this method, with 86% of excess weight loss two years after the surgery. With this thecnique we are able to reduce surgery time, avoid ring complications (ersion, sleepage), getting the same percentual of excess weight loss not using ring, no nutricional effects in long term, and much better eating quality for the patients.

## Bariatric Surgery - P118

THROMBOSIS OF THE LAP-BAND SYSTEM, Danny A Sherwinter MD, colin J Powers MD, Alan C Geiss MD, Syosset Hospital, North Shore Long Island Jewish Health System

The laparoscopic adjustable gastric band (LAGB) has proven itself a procedure with excellent long-term weight loss results and extremely low morbidity and mortality. The LAGB has become an indispensable addition to the armamentarium of most bariatric surgeons. Common complications associated with the Lap Band system include gastric prolapse, band erosion, hardware infection and port/tubing leakage. We report a case of a patient suspected of having a Lap-Band leak. He presented with a clinical course of multiple adjustments without restriction and inability to aspirate the expected volume from the band. Following adjustment under fluoroscopy he became severely dysphagic. He underwent urgent operative exploration and was found to have an intact but over-inflated band. Under close inspection, a clot in the proximal band was noted acting as a ball valve allowing the addition of fluid but not aspiration. This case highlights the absolute importance of preventing blood and particulate matter from entering the Lap-band system both at the initial operation and at subsequent adjustments.

<figure><img src="image_86.png" /></figure>

## Bariatric Surgery - P119

TWO STEPS LAPAROSCOPIC BILIO-PANCREATIC DIVERSION WITH DUODENAL SWITCH AS TREATMENT OF HIGH-RISK SUPER OBESE PATIENTS: ANALYSIS OF COMPLICATIONS, GIANFRANCO SILECCHIA PhD, ALESSANDRO PECCHIA MD, GIOVANNI CASELLA MD, MARIACHIARA FIORITI MD, MARIO RIZZELLO MD, FRANCESCO GRECO MD, NICOLA BASSO MD, Department of Surgery ?Paride Stefanini?, Policlinico ?Umberto I?, University ?La Sapienza? Rome, Italy

**AIM:** To prospectively analyze the incidence of complications after 2 steps laparoscopic bilio-pancreatic diversion with duodenal switch (Lap BPD-DS) in high risk super-obese patients.

**METHODS:** Between 10/2002 and 08/2006, 71 high risk super-obese patients (BMI>50 kg/m2 with at least 2 major comorbidities: diabetes, OSAS, hypertension) underwent Lap BPD-DS first step (sleeve gastrectomy) (GROUP I, M=28, F=43, mean age 43,3±10 years). Mean BMI was 56,5±6 kg/m2. 4 patients with Prader-Willi syndrome were included in the study. First step was performed using 5 trocars, harmonic scalpel or radiofrequency dissector and linear stapler to obtain a 100-120 ml gastric pouch. After 9-16 months 25 patients (GROUP II, BMI 43±8 kg/m2) underwent second laparoscopic step of BPD-DS (duodeno-ileostomy, ileoileostomy, common channel 100 cm).

**RESULTS:** 3 conversions for massive hepatomegaly occurred (3,1%). In one case the procedure was completed in a single step. GROUP I: Mean operative time was 105±10 minutes with a preoperative mean ASA score 3,4±05. Mean post-operative hospital stay was 5,5 days. In 5 cases the procedure was indicated as revision for failure of adjustable gastric banding. Major post-operative complications were registered in 11 patients (15,4%): 8 bleeding; 2 stapler-line leakage; 1 transient acute renal failure. One laparoscopic reoperation for hemoperitoneum was carried out. 1 patients dead for pulmonary embolia. GROUP II: Mean operative time was 201±27 minutes with a pre-operative mean ASA score 2,7±0,8. Major post-operative complications were registered in 5 patients (20%): 2 bleeding, 2 duodeno-ileal stenosis, 1 rhabdomyolysis. One case of internal hernia required laparoscopic reoperation. Overall reoperation rate was 2/96 (2%).

**CONCLUSIONS:** Two steps Laparoscopic Bilio-Pancreatic Diversion with duodenal switch seems to be an attractive alternative in high risk super-obese patients, in order to reduce mortality and major postoperative complications. Laparoscopic sleeve gastrectomy is a standard, safe and effective procedure inducing a significant Excess Weight Loss before second step. The high incidence of post-operative complications was registered in cases of revisional surgery.

## Bariatric Surgery - P120

MANAGEMENT OF RETAINED AND SECONDARY COMMON BILE DUCT STONES AFTER ROUX-EN-Y GASTRIC BYPASS SURGERY: CASE REPORT & REVIEW OF THE LITERATURE, Ian Soriano MD, Olga Tucker MD, Juan Salceda MD, Ramon Mourelo MD, Almudena Moreno MD, Samuel Szomstein MD, Raul J Rosenthal MD, Cleveland Clinic Florida

**Background:** The presence of common bile duct stones at the time of cholecystectomy or retained stones after a com-
SAGES POSTER ABSTRACTS

mon bile duct exploration in a patient with a previous roux-en-y gastric bypass surgery represents a diagnostic and therapeutic challenge because oral access to the biliary tract is lost.

**Methods:** We present an interesting case and review the literature to identify the diagnostic and therapeutic options available and propose an algorithm for managing this uncommon but difficult entity. Results: A 32-year-old female presented 4 years after undergoing a laparoscopic Roux-en-Y gastric bypass with right-upper quadrant pain, nausea and vomiting. Work-up revealed cholelithiasis and choledocholithiasis. She underwent a laparoscopic cholecystectomy, intraoperative cholangiogram, t-tube placement and outpatient radiologic stone extraction to manage both secondary common duct stones and subsequent retained stones. An algorithm for managing secondary and retained common bile duct stones is presented. Conclusions: Clinical presentation and diagnosis of common bile duct stones in the post-gastric bypass patient are as diverse as each patient, and there are several treatment options – both operative and non-operative. Given the complexity of the situation, an algorithmic approach is appropriate. Both the bariatric and the general surgeon who manage these patients should know all available techniques and select the intervention most appropriate for each case.

## Bariatric Surgery – P121

**BARIATRIC OPERATIONS: LOW MORTALITY IN A HIGH VOLUME BARIATRIC SURGERY CENTER, D J Stephens MD, J K Saunders MD, S Belsley MD, H Schmidt MD, A Trivedi MD, D Ewing MD, R Capella MD, V Iannace MD, D Davis MD, A Wasielewski RN, S Moran, G H Ballantyne MD, Hackensack University Medical Center**

Certification as a Center of Excellence is now required for Medicare patients. This mandate assumes that specialty centers achieve superior outcomes. Do high volume bariatric surgery centers, in fact, achieve a low operative mortality?

**AIMS:** The aim of this study was to determine the in-hospital mortality for patients in our high volume bariatric surgery center over the last nine years. **METHODS:** Electronic medical records for all patients undergoing bariatric operations at Hackensack University Medical Center between 1998 and July 2006 were retrieved. This database was queried for patient characteristics, types of procedures, hospital length of stay, and status at discharge.

<table><thead><tr><th>Year</th><th>1998</th><th>1999</th><th>2000</th><th>2001</th><th>2002</th><th>2003</th><th>2004</th><th>2005</th><th>2006</th><th>Totals</th><th>Mortality</th></tr></thead><tbody><tr><td>Total</td><td>116</td><td>183</td><td>288</td><td>543</td><td>918</td><td>984</td><td>964</td><td>938</td><td>423</td><td>5365</td><td>0.13%</td></tr><tr><td>RYGB</td><td>111</td><td>156</td><td>209</td><td>240</td><td>330</td><td>412</td><td>318</td><td>225</td><td>98</td><td>2099</td><td>0.19%</td></tr><tr><td>LRYGB</td><td>5</td><td>27</td><td>79</td><td>268</td><td>470</td><td>421</td><td>427</td><td>355</td><td>125</td><td>2177</td><td>0.14%</td></tr><tr><td>LAGB</td><td>0</td><td>0</td><td>0</td><td>35</td><td>118</td><td>151</td><td>219</td><td>358</td><td>208</td><td>1089</td><td>0.00%</td></tr><tr><td>Deaths</td><td>0</td><td>1</td><td>0</td><td>1</td><td>2</td><td>0</td><td>0</td><td>3</td><td>0</td><td>7</td><td></td></tr></tbody></table>

**RESULTS:** 5365 patients underwent bariatric operations at our center between 1998 and July 2006: 2099 open gastric bypasses (RYGB), 2177 laparoscopic gastric bypasses (LRYGB) and 1089 laparoscopic adjustable gastric bandings (LAGB). 75.5% were women and 24.5% men. Median age was 41 (13-79 years old), Body Mass Index 45.5 kg/m2 (35-92) and hospital length of stay for all patients 3 days (1-46). Three patients died following LRYGB (0.14%), four following RYGB (0.19%) and none after LAGB with an overall mortality of 0.13% for all bariatric procedures. **SUMMARY:** During a nine year period, 5365 bariatric operations were accomplished at Hackensack University Medical Center with an overall mortality of approximately 1 in 1000 patients. These findings support the concept that high volume Bariatric Surgery Centers achieve excellent outcomes and suggest that surgical volume may represent an appropriate criterion for certification as a Center of Excellence.

## Bariatric Surgery – P122

**DOES REQUIRING SMOKE CESSATION PRIOR TO BARIATRIC SURGERY PRODUCE SUSTAINED SMOKING ABSTINENCE, Stephanie Strauss MD, Steven J Heneghan MD, Bassett Healthcare, Cooperstown New York**

**Introduction:** Bariatric surgery when performed in appropriate candidates has been shown to produce long term health

benefits. Nicotine use currently is the single behavioral issue that produces more illness as compared to obesity in Americans. Whether requiring smoking cessation prior to bariatric surgery produces long term abstinence is currently unknown. The purpose of this study is to examine the success of requiring smoking cessation prior to approval for bariatric surgery in producing long term abstinence.

**Methods:** All patients who had undergone bariatric surgery at a single institution were examined over a three year period. Program requirement included a 15 pound weight loss and smoking cessation for 30 days proven by urine analysis in all smokers. An anonymous written survey was mailed to 193 consecutive surgical patients. Ninety eight had undergone laparoscopic adjustable gastric banding and ninety five had undergone laparoscopic roux-en-y gastric bypass. There were no mortalities in either group at 30 days and at study follow-up which approximated 18 months. 100 of the 193 (52%) patients responded to the survey which asked if they had been smoking prior to surgery and whether they were currently smoking.

**Results:** Twenty of the 100 responders indicated they were smokers within 30 days of orientation to our program. Eleven (55%) of the twenty stated they were currently not smoking. Nine (45%) of the 20 stated they had resumed smoking by the time of the survey.

**Conclusions:** Requiring both a modest weight loss and smoking cessation prior to bariatric surgery is feasible. In our population, 20% of surgical patients were able to lose 15 pounds and stop smoking prior to bariatric surgery. Smoking cessation prior to bariatric surgery leads to sustained abstinence in over 50% of patients at 18 months.

## Bariatric Surgery – P123

**OUR PRACTICAL PROCEDURE FOR LAPAROSCOPY-ASSISTED DISTAL GASTRECTOMY WITH LYMPH NODES DISSECTION, Tatsushi Suwa MD, Kenichi Okada MD, Tomoyuki Tamada MD, Tomomi Sata MD, Tomoo Shatari MD, Takayuki Furuuchi MD, Yoshifumi Takenaka MD, Masayoshi Sakuma MD, Mito Red Cross Hospital**

Laparoscopy-assisted gastrectomy (LAG) has been performed widely these days. LAG usually needs more surgical members and longer operation time than conventional open surgery. We have developed practical procedure that needs only two surgeons and shorter operation time. Our procedures are following.

1. A 5 cm upper median incision was made. Using Kent mini-retractor, the lymph nodes dissection along the right gastroepiploic vessels were performed.

2. A 12 mm trocar was inserted below the navel for a laparoscope and a 5 mm trocar was inserted in the upper right abdomen for a snake retractor to pull up lateral segment of liver, and a 12 mm trocar was inserted in the upper left abdomen for operator's right hand. An abdominal wall sealing device (Lap-Disk) was used for a 5 cm incision and a 12 mm trocar was set for operator's left hand through Lap-Disk.

3. Laparoscopically, additional dissection for lymph nodes along the right and left gastroepiploic vessels were made, and the lesser omentum was cut. The stomach was pulled up using taping technique, which helps to get better surgical view in the deep area along the left gastric vessels. The left gastric vein and artery was clipped and cut safely. The lymph nodes along the lesser curvature were dissected laparoscopically.

4. Through a 5 cm incision, the stomach was cut by Linearcutter at the oral excisional line. By pulling up the distal stomach through a 5 cm incision, the base of right gastroepiploic vessels were easily identified and exposed, then the suprapyloric and inflapyloric lymph nodes were dissected and the right gastroepiploic vessels were tied and cut.

5. The duodenum was cut with purse-string suture device (Purstring) and the resectional stomach was cut off. The anterior wall of residual stomach was partially cut and opened. Through this small window, the gastroduodenostomy was made by the anastomotic devise (ILS 29 mm) with the double-stapling technique. The small anterior wall window was closed by hand suturing.

<figure><img src="image_87.png" /></figure>
<figure><img src="image_88.png" /></figure>

# SAGES POSTER ABSTRACTS

## RESULT

We have performed this LADG procedure in over 50 cases. The mean operation time was within 3 hours with less blood loss. The outcome of this procedure was excellent.

## Bariatric Surgery - P124

THE FOLLOW-UP METHOD FOR REMNANT STOMACH AFTER LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS OF MORBID OBESITY- APPLICATION OF DOUBLE-BALLOON INTESTINAL ENDOSCOPY-, Nobumi Tagaya1) PhD, Kazunori Kasama2) PhD, Eiji Kanehira2) PhD, Keiichi Kubota1) PhD, 1)Second Department of Surgery, Dokkyo Medical University, Tochigi, 2)Department of Surgery, Yotsuya Medical Cube, Tokyo, Japan

Morbid obesity has become a serious social problem. The treatment for complications associated with morbid obesity is necessary. We had applied laparoscopic Roux-en-Y gastric bypass for morbid obesity from February 2002. Although the complications associated with morbid obesity were improved by surgical procedure, the investigation of remnant stomach after surgery is still not resolved. The patient who had the family history of gastric cancer was added the resection of remnant stomach, however, it required more operation time. There are two major problems with regard to performing this procedure in Japan: the high occurrence rate of gastric cancer and how to investigate the remnant stomach. To resolve these problems we introduced double-balloon intestinal endoscope to observe the remnant stomach. We reported the technique of double-balloon intestinal endoscope for the remnant stomach after laparoscopic Roux-en-Y gastric bypass of morbid obesity. There was no trouble to put the endoscope forward with observation. We used an overtube same as routine work of oral endoscope. Although a learning curve is necessary to perform double-balloon intestinal endoscope, there were no major obstacles for the observation and passage of esophagus, gastric small pouch, lifted jejunum, the jejunojejuno-anastomosis, Y loop, duodenum and remnant stomach. The use of double-balloon technique enabled us to observe the gastrointestinal tract after laparoscopic Roux-en-Y gastric bypass without the influence of length between gastrojejunostomy and jejunojejunostomy.

## Bariatric Surgery - P125

FACTORS PREDICTING GASTROJEJUNOSTOMY STRICTURE AFTER GASTRIC BYPASS FOR MORBID OBESITY, Mark Takata MD, Ruxandra Ciovica MD, Stanley Rogers MD, John Cello MD, Eric Vittinghoff PhD, Guilherme M Campos MD, Bariatric Surgery Program, University of California San Francisco.

**Background:** Gastrojejunostomy stricture after gastric bypass (GBP) has been reported in 4% to 27% of patients. Objectives: To determine factors that predict gastrojejunostomy (GJ) stricture following GBP. Setting: University tertiary referral center.

**Patients:** Three-hundred and sixty-two consecutive morbidly obese patients that underwent open or laparoscopic GBP. Outcome Measure: GJ stricture following GBP requiring endoscopic dilatation.

**Methods:** Proportions were compared using Fisher's exact test. Logistic regression was performed to define the independent predictors of stricture. Predictors considered were age, gender, BMI, comorbidities, surgical technique (linear vs. EEA 21mm vs. EEA 25mm circular stapler; open vs. laparoscopic; retrocolic vs. antecolic roux), and surgeon experience (< 51 cases).

**Results:** Sixteen of 362 patients (4.4%) developed a stricture. The frequency was higher after EEA 21mm compared to linear stapler and EEA 25mm techniques. A higher rate of strictures was found with retrocolic roux (Table).

<table><thead><tr><td>Technique</td><td>n (%)</td><td>Stricture n(%)</td></tr></thead><tbody><tr><td>Linear Stapler</td><td>195 (53.9)</td><td>9 (4.6)</td></tr><tr><td>EEA 25mm</td><td>154 (42.5)</td><td>4 (2.6)</td></tr><tr><td>EEA 21mm</td><td>13 (3.6)</td><td>3 (23.1)*</td></tr><tr><td>Antecolic Roux</td><td>297 (82)</td><td>10 (3.4)</td></tr><tr><td>Retrocolic Roux</td><td>65 (18)</td><td>6 (9.2)**</td></tr></tbody></table>

*p=0.01 21 vs. 25mm, p=0.03 21mm vs. Linear, **p=0.048 ante vs. retrocolic).

There was a trend toward higher stricture rate related to surgeon experience (7.4% first 50 cases vs. 2.6% after, p=0.06). The use of EEA 21mm was the only independent predictor of a stricture (odds ratio 6.2; 95%CI 1.5-26, p=0.01). Conclusion: The use of an EEA 21mm stapler strongly predicts GJ stricture following GBP. The EEA 25mm and the linear stapler techniques have similar and low stricture rates.

## Bariatric Surgery - P126

WEIGHTLOSS SURGERY AFTER NISSEN FUNDOPLICATION: CONSIDERATION FOR LAPAROSCOPIC SLEEVE GASTRECTOMY, Janos Taller MD, Jay Grove MD, Department of Surgery, Naval Medical Center, San Diego

Clinically, obesity and GERD go hand-in-hand. The obesity epidemic continues to affect patients who have had anti-reflux procedures many years ago. These operations, often performed by laparotomy, add to the complexity in the re-operative arena. Descriptions of weight loss procedures after anti-reflux operations in the obese are controversial at best. Some authors suggest conversion to RGB as the procedure of choice. We propose that the vertical sleeve gastrectomy (VSG) is a simpler and superior alternative. Our patient is a 47 y/o female with previous open Nissen fundoplication & cholecystectomy for severe GERD. Her lifelong struggle with obesity also remains an issue. Recent weight gain of 50+ lbs over the last 5 years has contributed to her hyperlipidemia and worsening GERD & DJD. She is 68 inches tall and weighs 241 lbs with a BMI of 37+. Her physical exam was notable only for a large vertical midline abdominal scar. Preoperative UGI confirmed the presence of an intact fundoplication. She completed our pre-operative bariatric program and desired a "restrictive only" procedure for weight loss. She consented to laparoscopic conversion of Nissen fundoplication to VSG, possible open.

A total of 4 ports were used for her operation. Extensive adhesiolysis provided access to the upper abdomen to define her fundoplication. Her wrap was taken down with blunt dissection & electrocautery. A sleeve gastrectomy was then performed with endoscopic staplers along a 32 French bougie beginning 8 cm proximal to the pylorus and carried vertically up to the angle of His. The integrity of the gastric pouch was tested with methylene blue and a JP drain left in the re-operative field.

Her operation was completed in 204 minutes with 150 ml EBL. UGI on POD#1 revealed no leak. Her drain was removed on POD#2 and she was discharged home on a bariatric liquid diet. She experienced no complications and has lost 30 pounds as of her 5 week follow-up. She now rarely has reflux and her back pain has resolved. VSG has traditionally been described as the first stage to a more complex weight loss procedure. In the face of previous anti-reflux surgery and the hostile post-operative abdomen, we propose the Lap VSG is a safe procedure that may be offered to patients pursuing weight loss surgery. Further more, lacking the requirement for substantial small bowel adhesiolysis and mobilization or anastomosis, the Lap VSG may prove to be the simpler, more desirable, procedure.

## Bariatric Surgery - P127

LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING (LAGB) IN SUPER-OBESIVE PATIENTS, THE RIGHT CHOICE?, Wouter W te Riele MD, J M Vogten PhD, D Boerma PhD, M J Wiezer PhD, B van Ramshorst PhD, Sint Antonius Ziekenhuis, Nieuwegein, the Netherlands

**Introduction** To address the issue of long term efficacy of LAGB in the treatment of superobese patients (body mass index [BMI] >50 kg/m2), we have performed a single-center study of LAGB in superobese patients (BMI>50 kg/m2).

**Methods** Patients who underwent LAGB in our institution between 1995 and 2006 were included in the study. The study population was divided into a superobese group (SO) with a BMI >50 kg/m2, and a control group with a BMI <50 kg/m2. Primary end point was percentage of successfully
treated patients after 5 years of follow-up. Successful treatment was defined as an excess weight loss (EWL) of at least 30%. Mann-Whitney U and Chi-squared tests were conducted to evaluate continuous and discrete variables, respectively. P-values <0.05 were considered significant.

**Results** 491 patients were subjected to LAGB. 107 patients were included in the SO group, 384 patients were included in the control group. There was no difference in age (39.0 vs 38.5; p=0.4) or gender distribution (men 15.0 vs 16.7%; NS) between both groups. Median preoperative BMI was 54.0 kg/m2 in the SO group (50.0-71.7 kg/m2) versus 43.7 kg/m2 in the control group (36.2-49.9 kg/m2) (p<0.001). Median follow-up was 48 months (4-117 months) in the SO group versus 45 months (2-127 months) in the control group (p=0.55). In both groups, 15% (58/384 vs 16/107; NS) of patients were lost to follow-up after 5 years.

No mortality was observed in either group. The conversion rate was significantly higher in the SO group as compared to the control group (10,3 vs 2,1%; p<0,001). Complication rates were comparable and included band slippage (13,0 vs 13,1%; NS), port-a-cath complications (8,3 vs 8,4%; NS), wound infection (4,2 vs 4,7%; NS) and reoperations due to complications (25,3 vs 28,0%; NS) in the SO and control group, respectively. The number of patients that underwent secondary gastric bypass surgery due to insufficient weight loss was significantly higher in the SO group (18,7 vs 2,3%; p<0.001).

Median excess weight loss 5 years after surgery was 39.0% in the SO group and 39.8% in the control group. The percentage of successfully treated patients 5 years after LAGB was significantly lower in the SO group than in the control group (49,9 vs 65,0%; p<0,01).

**Conclusion** In super-obese patients the minimally invasive LAGB is successful in 50% of cases after a 5 year follow-up period. These findings should be taken into account in the surgical management of super-obese patients.

## Bariatric Surgery - P128

### EVALUATION OF PERIOPERATIVE DEXMEDETOMIDINE ADMINISTRATION FOR LAPAROSCOPIC GASTRIC BYPASS,
Gregory J Tillou MD,Tejinder Paul Singh MD,James Karambay BS,Rakesh Ramakrishnan BS,Melanie Loewenthal BS, Dept of Surgery, Albany Medical Center, Albany, NY

**PURPOSE:** To evaluate the effects of administering dexmedetomidine, a selective alpha-2 receptor agonist with sedative and analgesic properties, to patients undergoing laparoscopic Roux-en-Y gastric bypass performed by a single surgeon. Of main concern was the drugs effect on postoperative pain, narcotic requirements, respiratory status, and length of hospitalization.

**METHODS:** A retrospective analysis of a single surgeon's experience with dexmedetomidine administration during lap RNY GBP was performed by chart review of patients undergoing the procedure from 1/06 thru 8/06 at a single institution. A total of 60 lap GBP were performed - 13 patients were excluded from review (4 for incomplete data, 2 for undergoing concomitant surgical procedures, 3 for history of chronic pain, and 4 for history of narcotics abuse). Of the remaining patients 34 received a standardized administration of dexmedetomidine, and 13 received typical anesthetic/analogic agents. The majority of patients were female (35). The avg. age and BMI in the drug group was 48 and 47.5 respectively; in the control group 44.5 and 47.3 respectively. Comorbidities in both groups included tobacco use, DJD, diabetes, HTN, COPD, and obstructive sleep apnea and prevalence was similar in comparison groups.

A comparison of outcomes made by evaluating postoperative pain scores (scale of 1-10), narcotic administration/requirements (# of doses and total amount), supplemental oxygen requirements and respiratory rate at multiple points within the first 24hrs post op. Total length of hospitalization was also evaluated. Student's t test and non-parametric analyses were used for statistical analyses.

**RESULTS:** There were no statistically significant differences between the two groups among the parameters evaluated. Pain scores were similar between the two groups at all points measured during the first 24 hrs (p= 0.18, 0.46, and

0.48). In addition, the average pain score for 24 hrs was also similar (p=0.48). The total number of doses of narcotics received and total amounts were also similar between the two groups and showed no statistically significant difference. Length of hospitalization was equivalent (4.07 day and 4.16 days).

**CONCLUSIONS:** The administration of dexmedetomidine during lap GBP does not appear to influence postoperative pain, narcotic requirements, or length of stay, nor did use cause or prevent any untoward respiratory events. Further study necessary.

## Bariatric Surgery - P129

### MOVING TO LAPAROSCOPY FOR BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH WITHIN THE LEARNING CURVE: WHAT DIFFERENCE DOES IT MAKE?, Philippe Topart MD,Loic Ferrand MD,Patrick Lozach MD, Chirurgie Generale, Centre Hospitalier Universitaire Brest, 29609 Brest, cedex, France

From February 2002 to June 2006 we intended to perform 84 biliopancreatic diversions with duodenal switch (BPD-DS) (Marceau procedure). The first 24 patients had open surgery (BPD) for a BMI of 46.4 ± 6.8. The 60 most recent operations were begun laparoscopically (LBPD) for patients with a BMI of 49.8 ± 7. There was no difference in age between the 2 groups (mean 43.4 and 41.5 respectively). 8 BPD (33%) and 13 LBPD patients (21.6%) had a previous bariatric surgery (all but one gastric banding). One patient in BPD and 3 in LBPD had only a sleeve gastrectomy because of cirrhosis, ventilatory problems during laparoscopy or poor exposure/adhesions. Of the remaining 57 LBPD patients, 21 (36.8%) were converted to open: 4 deliberately, 9 for poor exposure/adhesions, 1 inability to create pneumoperitoneum, 3 duodenal injuries, 3 staplers problems and 1 bleeding. The operation duration was significantly longer for LBPD (245 ± 45 mn) compared to BPD (190 ± 41 mn) (p<0.0001) but the hospital stay was significantly shorter after LBPD (8.6 ± 8.6 days) than after BPD (13.8 ± 14 days) (p=0.049). For the 36 totally laparoscopic cases of LBPD the operative time was 234 ± 40 mn. Although there were more complications after BPD (47.8%) there was no significant difference with LBPD (35%). The rate of anastomotic leak/intraabdominal abcess was also higher after BPD (21.7% vs12.7%) but not significant. There was one postoperative death (1.7%) in the LBPD group after conversion to open in a BMI 80 patient who developed gluteal rhabdomyolysis. 2 of 23 BPD patients (8.7%) were reoperated on for their complications (leaks/intra abdominal abcess and bleeding) compared to 9 LBPD (15.8%) but this was not significant. 3 BPD and 9 LBPD patients were readmitted (for bowel obstruction, vomiting, hypoalbuminemia). The rate of late reoperation was significantly higher after BPD (65%) compared to LBPD (12.5%) with p<0.0001. Indications were incisional hernia (12 BPD and 2 LBPD patients) and revision/reversal (2 BPD and 5 LBPD patients) and the revision rate was similar between the 2 groups. At 2 years both groups share a mean BMI of 31. Because of a higher preoperative BMI the weight loss after LBPD is greater although not significant. Although responsible for a significantly longer operative time with a high conversion rate the move to laparoscopy for BPD-DS adding a «learning curve within the learning curve» did not worsen the initial results with a comparable effect on weight loss.

## Bariatric Surgery - P130

### SINGLE-STAGE LAPAROSCOPIC SLEEVE GASTRECTOMY FOR WEIGHT LOSS IN MORBID OBESITY, O Tucker MD,T Escalante-Tattersfield MD,P Lalor MD,S Szomstein MD,R Rosenthal MD, The Bariatric Institute, Cleveland Clinic Florida, Florida, USA

Laparoscopic sleeve gastrectomy (LSG) is now considered an alternative surgical option for morbid obesity. We performed a retrospective review of a prospectively maintained database of patients undergoing LSG from Nov 2004 to Sept 2006 as a one-stage restrictive procedure.107 LSGs were performed. 93 (87%) were primary procedures; M:F=1:3,
<figure><img src="image_89.png" /></figure>

SAGES POSTER ABSTRACTS

mean age 42 yrs (range 13-79), mean BMI 43kg/m2 (range 35-66). All procedures were completed laparoscopically. The mean duration of surgery was 94 mins (range 60-180) with a mean blood loss of 65 mls (range 20-300). The mean length of hospital stay was 2 days. 1 patient underwent reintervention for abdominal pain on postoperative day (POD) 1 requiring laparoscopic primary closure of a staple line leak close to the gastrooesophageal junction. Short-term outcome data is available on 66 patients (71%) who have been followed for >3 mon; 52 patients (56%) have >6 mon follow-up with >1 yr follow up in 16 patients (17%). The mean weight loss is 24kg (range 19-30) at 6 mon and 51kg (range 24-44) at 1 yr. A further 14 patients (13%) had a LSG after failed laparoscopic adjustable gastric banding (n=11), failed attempt at laparoscopic Roux-en-Y gastric bypass due to adhesions (n=1), or previous jejunoileal bypass with weight regain (n=2); M:F=1:4, mean age 48 yrs (range 16-69), mean BMI 41kg/m2 (range 35-55). Only 1 procedure was not completed laparoscopically (7%). This patient had a jejunoileal bypass >30 yrs previously and had chronic renal and liver failure. All 11 laparoscopic adjustable bands were removed during the same procedure. Mean operative time was 122 mins (range 85-180), mean blood loss was 98 mls (range 40-200), and mean length of hospital stay was 2.9 days (range 2-4). 1 patient underwent reintervention for abdominal pain on POD 2 requiring primary closure and omental patchplasty of a presumed ischaemic perforation adjacent to the staple line secondary to a coagulation injury. In summary, 2 patients required reintervention in our series resulting in a major complication rate of 1.8%. All patients had a gastro-graffin swallow on POD 1 allowing early leak detection. A further 3 patients required readmission for mild dehydration. In conclusion, LSG is an effective and safe primary restrictive procedure to achieve weight loss.

Bariatric Surgery – P131

THE ROLE OF THE BARIATRIC SURGEON IN ENDOSCOPIC MANAGEMENT OF PATIENTS AFTER WEIGHT LOSS

**SURGERY,** O Tucker MD,S Szomstein MD,P Fajnwaks MD,T Escalante-Tattersfield MD,E Matei MD,R Rosenthal MD, The Bariatric Institute, Cleveland Clinic Florida, Florida, USA

**Introduction:** In Jan 2005 at the Bariatric Institute, Cleveland Clinic Florida, we initiated a program of bariatric surgeon-performed upper gastrointestinal (GI) endoscopies on our bariatric patient population.

**Methods + Procedures:** A retrospective review was performed on all patients who had an upper GI endoscopy performed by two bariatric surgeons from Jan 2005 to Sept 2006.

**Results:** Since Feb 2000, 2238 laparoscopic bariatric procedures were performed; 1706 primary Roux-en-Y gastric bypass (LRYGB), 229 primary adjustable gastric bands, 92 primary sleeve gastrectomies. From Jan 2005 to Sep 2006, 862 upper GI endoscopies were performed; 394 in the endoscopy suite under sedation and 468 in the operating room under general anesthesia of which 412 (86%) were performed in patients undergoing LRYGB to check anastomotic integrity. In 1 patient (0.2%) the anastomosis was oversewn due to a minor leak demonstrated at upper GI endoscopy. Indications for postoperative endoscopic suite performed upper GI endoscopy were nausea (85%), vomiting (85%), epigastric pain (10%) or dysphagia (15%) after LRYGB. Findings included no abnormality in 108 (27%), mild gastritis in 60 (15%), moderate gastritis in 8 (2%), esophagitis in 17 (4%), gastrojejunal (GJ) anastomotic ulceration in 24 (6%), and GJ anastomotic stricture (GJAS) in 62 (16%). 96 balloon dilations were performed in 60 patients with GJAS. Only 7 (11%) required >3 balloon dilations for symptom resolution, while 38 (61%) required only 1 dilation. 4 of 62 (6%) patients with GJAS required surgical intervention; 2 for removal of silastic ring after vertical banded gastric bypass, and 2 with a persistent stricture. Endoscopic retrieval of pills, impacted food and bezoar was successful in 3 patients with pouch outlet obstruction. Endoscopic removal of eroded bands were performed successfully in 2 patients avoid-

ing the need for surgery. Complications included non-lethal arrhythmia in 2, hypoxemia in 1, and GJ perforation post dilation requiring laparoscopic repair in 3 (5%).

**Conclusions:** In our experience, bariatric-surgeon performed upper GI endoscopy is safe, and facilitates management of postoperative complications.

Bariatric Surgery – P132

IS CONCOMITANT CHOLECYSTECTOMY NECESSARY IN OBESE PATIENTS UNDERGOING LAPAROSCOPIC GASTRIC BYPASS SURGERY?, O Tucker MD,P Fajnwaks MD,T

Escalante-Tattersfield MD,S Szomstein MD,R Rosenthal MD, The Bariatric Institute, Cleveland Clinic Florida, Florida, USA Routine cholecystectomy in patients undergoing laparoscopic gastric bypass is controversial. Morbid obesity is associated with a high prevalence of cholecystopathy and increased risk of cholelithiasis during rapid weight loss. Trans-oral access to the biliary tree is lost after gastric bypass. In the era of open bypass surgery cholecystectomy was performed routinely to avoid a second laparotomy. We performed a retrospective review of a prospectively maintained database of patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) from Feb 2000 to Aug 2006. 1696 LRYGBs were performed. All had a preoperative USS to detect gallbladder (GB) pathology. 42 (2.5%) had previous cholecystectomy and were excluded from further analysis. 205 (12%) had GB pathology; cholelithiasis in 199 (83%), sludge in 5 (4%), and a polyp in 1 (0.5%). Cholecystectomy was not indicated for sludge or polyp size <1cm. 123 patients (60%) had a concomitant cholecystectomy at LRYGB, while 82 patients (40%) did not. Of these 120 (97%) were completed laparoscopically with insertion of an additional 5mm operating port. Concomitant cholecystectomy added a mean operative time of 20 mins (range 15-25). One patient developed a bile leak from an accessory biliary radicle requiring diagnostic laparoscopic transgastric ERCP (LTG-ERCP). Of the 82 patients who did not have cholecystectomy 16 (19%) have required subsequent cholecystectomy presenting with biliary colic (n=8), acute cholecystitis (n=6), and choledocholithiasis (n=2). All procedures were completed laparoscopically. 1 patient required transcystic CBD exploration (TCCBDE) with stone retrieval. 89 patients (5.2%) without preoperative GB pathology developed symptomatic cholelithiasis after LRYGB. Of these, 69 (4%) had a cholecystectomy, of which 98.5% were completed laparoscopically. 3 patients presented with gallstone pancreatitis and 2 with obstructive jaundice. 3 required TCCBDE and 1 LTG-ERCP with stone retrieval. 20 patients (1%) did not have further surgery. Another patient who had a cholecystectomy in 1983 presented with choledocholithiasis requiring LTG-ERCP with stone retrieval. In our experience, concomitant cholecystectomy at LRYGB for GB pathology is safe, feasible, and avoids subjecting patients to a second surgical procedure.

Bariatric Surgery – P133

COMPLICATIONS OF SLEEVE GASTRECTOMY WITH WRAPPING USING PTFE IN A PORCINE MODEL, Kazuki Ueda MD,Michel Gagner MD,Luca Milone MD,Sergio J Bardaro MD, Weill Medical College of Cornell University & Kinki University School of Medicine

**Background:** The safety and efficacy of laparoscopic sleeve gastrectomy for morbid obesity has been well established. However, short term weight regain may occur due to gastric dilatation. The efficacy and feasibility of the sleeve gastrectomy with wrapping using PTFE dual mesh was previously demonstrated. ?@The aim of the study was to review complications of gastric wrapping using PTFE dual mesh.

**Methods:** Eleven Yorkshire pigs weighing 20-25kg underwent the sleeve gastrectomy with wrapping using PTFE dual mesh (wrap group, 8 pigs) or sleeve gastrectomy only (control group, 3 pigs) to compare weight loss. The operative procedure in the wrap group was performed: 1) omental dissection with left gastroepiploic vessels and short gastric vein dissection, 2) creation of gastric sleeve (approximately 200ml of size) using endoscopic linear staplers, 3) creation of two windows and tunnels at the lesser omentum, 4) wrap
up the gastric sleeve with PTFE dual mesh (17X14cm) and attach with endoscopic linear staplers. The postoperative animals were weighed weekly up to 8 weeks.

**Results:** Initial body weight, Operation time, and removed stomach size were similar in both groups. Postoperative weight gain up to 8 weeks was significantly slower in the wrap group than in the control group (p=.0007). Minor complications include such as regurgitation, vomiting, appetite loss, and port site infection. Those complications were improved within 1 week after surgery. In major complication, two mortalities (one was in the control group and another one was in the wrap group) were seen due to staple line failure and small bowel obstruction. After the completion of 8-week observation, of 7 pigs in the wrap group, the gastric erosion due to PTFE dual mesh were seen in 3 animals (38%).

**Conclusion:** Sleeve gastrectomy with wrapping using PTFE dual mesh is feasible and slow weight gain in a porcine model producing less gastric distention. However, PTFE dual mesh gastric wrapping resulted in erosion in 38% of animals. This material is not the ideal compound for gastric wrapping, and a new biomaterial need to be tested before human application.

## Bariatric Surgery - P134

**STAPLE LINE REINFORCEMENT IN LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS: SEAMGUARD OR PERISTRIPS?,**
Sherman Yu MD, Terry Scarborough MD, Erik Wilson MD, The university of texas health science center houston

**Introduction** With the increase in the use of staple line reinforcement in laparoscopic Roux-en-Y gastric bypass (LRYGB), there is little evidence to determine which product to use. The most touted benefit has been a decrease in intra-operative and post-operative bleeding. There are two main products. Peri-strips is non-absorbable whereas, Seamguard is bio-absorbable. Our aim is to determine if one product has an advantage over the other in LRYGB.

**Materials and Methods** From a prospectively collected bariatric database, all patients who had their gastric pouches created with Peri-strips were compared to the same number of consecutive patients who had Seamguard used instead. All patients underwent a LRYGB performed similar to the Higa technique. Outcomes and complications were tracked for 12 months after surgery. Patient complications associated with the gastric pouch were compared with the chi-squared method.

**Results** From November 2002 until November 2003, 118 patients had their gastric pouches created using Peri-strips. Subsequently, we switched to Seamguard and reached 118 patients by August 2004. Pre-operative factors for Peri-strips versus Seamguard patients were similar, including BMI (49.9 vs. 50.1), age (43 vs 44) and number of comorbidities (5.8 vs 5.8). There were no re-operations or postoperative bleeding requiring transfusion in either group. One patient in this study died secondary to a pulmonary embolus. The Peri-strips group had no leaks, whereas the Seamguard group had one subclinical anastomotic leak (p=.32). Nausea and vomiting were present in 3 patients with Peri-strips versus 8 patients with Seamguard (p=.12). Pouch erosion of Peri-strips was seen in 6 patients (5%), but not in any of the Seamguard patients (p=.01).

**Conclusions** The non-absorbable nature of Peri-strips resulted in pouch erosion in 5% of patients. However, nausea and vomiting was not statistically different between the two. These are often common complaints among the bariatric population, and their causes may be difficult to discern. Leak rates were also not statistically different and neither had a leak from the staple line of the gastric pouch. Both types of staple line reinforcements prevented significant postoperative bleeding. Seamguard is preferable to Peri-strips in LRYGB because it does not erode. A prospective, randomized trial would need to be performed to draw further conclusions.

## Bariatric Surgery - P135

**BENEFIT OF PATIENT CONTROLLED LOCAL ANESTHETIC INFUSION DEVICE AFTER LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS (LRYGB),**
John G Zografakis MD, Adrian G Dan MD, Mark Pozsgay DO, Debbie Pasini RN, Summa Health System Hospitals - Bariatric Care Center

**Background:** Morbidly obese patients are at increased risk for postoperative respiratory complications which may be compounded by the use of IV narcotics. This abstract details our experience with a non-narcotic based, patient controlled infusion catheter system.

**Methods:** 50 consecutive patients underwent LRYGB using a standard 6 port access method. At the completion of the procedure two fenestrated 5 cm catheters attached to the infusion device (300cc of 0.5% marcaine) were inserted into the subcutaneous tissue. The system delivers a constant 5cc/hour of local anesthetic, with the availability of a 2cc/hour bolus controlled by patient demand. The system is removed on the morning of POD#2. Other breakthrough medications available to the patient in addition to the infusion device include scheduled IV ketoralac, IV morphine and subsequently PO propoxyphene / acetaminophen on POD#1.

**Results:** Of the 50 patients, 48% (24/50) used 2 or fewer doses of IV narcotics. Of these 18% (9/50) used no IV narcotics after surgery and 15/50 (30%) used 1 or 2 doses. None of these patients had any pulmonary catheter site complications. There were no catheters that were inadvertently removed.

**Conclusion:** The use of a patient controlled, non-narcotic infusion device is an effective method of providing postoperative pain control with minimal respiratory complications in patients undergoing LRYGB. In addition, the use of this system allows patients to control their own pain medication, while allowing for a decrease in nursing time for medicine administration.

## Basic Science (cellular bio, physiology) - P136

**DIFFERENT PNEUMOPERITONEUM PRESSURES EFFECT THE PROPORTION OF CARBON DIOXIDE DIFFUSION THROUGH THE PERITONEUM AND THROUGH OPEN SMALL BOWEL AS REFLECTED BY END TIDAL CARBON DIOXIDE (ETCO2): OBSERVATION IN A SMALL ANIMAL MODEL,**
Shmuel Avital MD, Samuel Szomstein MD, Raul Rosenthal MD, Yehuda Sckornik MD, Avi A Weinbroum MD, Department of Surgery A1 and Post Anesthesia Care Unit3, Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel and Division of Laparoscopic Surgery2, Cleveland Clinic Florida, Weston, Florida, USA.

**INTRODUCTION:** We have previously demonstrated that end-tidal carbon dioxide (ETCO2) increases when the small bowel is perforated during CO2 pneumoperitoneum. The aim of this study was to assess the effect of this phenomenon in different CO2 pressure levels.

**MATERIALS AND METHODS:** Three groups of 8 Wistar rats each were anesthetized, tracheostomized, and mechanically ventilated with fixed tidal volume and respiratory rate with vital signs and ETCO2 monitoring. After a stabilization phase of 30 minutes, CO2 pneumoperitoneum was established to 5mmHg, 8 mmHg and 12mmHg in each different group and maintained for 30 minutes. A small bowel perforation was than created and pneumoperitoneum was maintained for another 30 minutes.

**RESULTS:** There were no significant changes in blood pressure throughout the experiment in all groups. Ventilatory pressures increased in all groups after induction of pneumoperitoneum and remained elevated during the pneumoperitoneum with bowel perforation. In the 5mmHg group, there was a significant modest increase in ETCO2 following induction of pneumoperitoneum (39.4 to 41.1, p=0.014), and a further increase following the small bowel perforation (41.1 to 42, p=0.001). In the 8 mmHg and 12mmHg groups, there was no significant change in ETCO2 after induction of pneumoperitoneum however; a dramatic

<figure><img src="image_90.png" /></figure>
<figure><img src="image_91.png" /></figure>

# SAGES POSTER ABSTRACTS

increase in ETCO2 in both groups was recorded following the small bowel perforation (39 to 50 in the 8 mmHg group, p=0.001 35.1 to 49.8, in the 12 mmHg group p=0.002).

**CONCLUSIONS:** ETCO2 increases when small bowel is perforated during CO2 pneumoperitoneum. The increase is pressure-dependent. Bellow a certain intraperitoneal pressure (5-7 mmHg in the rat), ETCO2 would increase mildly after induction of pneumoperitoneum and would further rise moderately upon perforating the bowel. In higher intra-abdominal pressure (>=8 mmHg in a rat), no increase in ETCO2 is predicted after induction of pneumoperitoneum. However, a substantial ETCO2 increase is expected following bowel perforation. As sustained before, there is a critical pneumoperitoneum pressure level, above which the peritoneal capillaries are pressurized, thus occluded, and CO2 diffusion is minimal. When small bowel is perforated it serves as the only port of exit for CO2 load, leading to a substantial increase in ETCO2. We believe such a gradient exists in humans, for which the magnitude of ETCO2 elevation could monitor small bowel perforation deliberately or accidentally.

## Basic Science (cellular bio, physiology) - P137

**THE EFFECT OF SURGERY ON GRANULOCYTE GENE EXPRESSION; A MICROARRAY ANALYSIS.**, A Belizon MD,I Kirman PhD,A Hoffman MD,S Kumara PhD,A Offodile BA,M Foster BA,D Moradi BA,S Jain BA,V Cekic RN,R L Whelan MD, Columbia University Medical Center

Animal models have consistently shown enhanced tumorigenesis after major surgical trauma, the cause of this enhanced growth remains unclear. We previously demonstrated, in humans, that surgical trauma causes significant alterations in the plasma levels of proteases and related factors which may have a stimulatory effect on tumor growth and spread early after surgery. Some of these alterations involve cells involved in the inflammatory response, particularly granulocytes. In this study, a focused microarray analysis was carried out in an effort to gain insight into how surgery affects the expression of genes related to protease regulation within granulocytes.

**Methods:** 8 pts between the ages of 65-75 undergoing elective minimally invasive sigmoid colon resection with the final pathologic diagnosis of adenocarcinoma between Aug 2005 and Jan 2006 were included in this study. After obtaining informed consent, blood was drawn preoperatively and on Postop days 1 and 3. Granulocytes were isolated from the blood using a combination of gradient centrifugation and magnetic microbead separation. The cells were subsequently lysed and the mRNA extracted after which the mRNA was hybridized to the GE Array Q series, a specialized microchip specific for 96 human protease related genes.

**Results:** Relative to the preop baseline, the mean expression level of 7 genes showed significant changes 24 hrs after surgery. In addition 5 genes showed significant alterations on postop day 3 when compared to their average preop expression. Of interest was the POD 1 downregulation of the integrin beta 7 gene, a protein known to be important in the adhesion and chemotaxis of cells involved in tumor growth regulation. Additionally, matrix metalloproteinase 9, 14 & 17 (all known tumor growth promoters) were significantly upregulated 24 hrs after surgery. On POD 3 TGF beta 1 expression was significantly increased when compared to baseline; TGF beta 1 is also implicated in tumor growth and spread. Conclusion: Surgical trauma affects the genetic expression of granulocytes in the immediate perioperative period. A number of the up-regulated genes are thought to play important roles in the regulation of tumor growth and spread. These findings need to be verified in a larger group of pts in microarray as well as via RT-PCR and on the protein level. Nevertheless, the microarray study of circulating immune cells merits further study and may provide further insight into surgery's impact on the host.

## Basic Science (cellular bio, physiology) - P138

**EARLY RESULTS OF THE USE OF NOVEL PROTEOMIC AND METABOLOMIC ASSESSMENT TOOLS TO ASSESS METABOLIC RESPONSE TO WEIGHT-LOSS IN PRE AND POST-LAGB PATIENTS.**, John M Bennett BA,Abigail C Polley PhD,Ian J Colquhoun PhD,Gwenalle Le Gall,Elizabeth K Lund PhD,Ian T Johnson PhD,Michael Rhodes MD, Institute of Food Research and BUPA Hospital Norwich

**Introduction:** The development of methods to separate and quantify all the components of the human proteome and metabolome allows us to explore the entire plasma response to obesity and obesity surgery. The use of these tools will enable the investigation of changes occurring in response to metabolic adjustments that occur during weight reduction following obesity surgery.

**Method:** We are undertaking a prospective, controlled study of morbidly obese patients undergoing laparoscopic adjustable gastric banding. Fasted blood tests are taken pre- and at 3 and 6 months post- surgery for obese patients and at identical time points for normal subjects to control for seasonal variations in metabolome expression. Proteomic assessment involves 2-D gel electrophoresis of albumin/ IgG depleted plasma using pH gradient strips and isoelectric focusing followed by gel separation on 10% homogenous polyacrylamide gels. Metabolomic assessment is based around liquid chromatography-mass spectrometry and nuclear magnetic resonance spectroscopy.

**Results:** Five morbidly obese patients, 4F and 1M (median age 40 years (27-55), mean pre-op BMI 47.3 Kg-m-2 (41.4-59) and three age/ sex matched controls (mean BMI of 24 (21-26) have been recruited and sampled to date. Pre- and 3 months post- operative plasma samples have undergone proteomic and metabolomic assessment. Initial results show a spectrum of protein changes that will be qualified using a robotic spot-picking system and identified by MALDI-TOF and Q-TOF mass spectrometry.

**Discussion:** The preliminary results show the viability of this method for broad spectrum metabolic assessment in this group, and its utility in the search for proteome and metabolome differences associated with obesity related disease.

## Basic Science (cellular bio, physiology) - P139

**LAPAROSCOPIC BARIATRIC SURGERY-INDUCED WEIGHT LOSS ENHANCES THE SPECIFIC IMMUNE SYSTEM.**, Silas M Chikunguwo MD,Stacy Brethauer MD,Vijaya Nirujog MD,Suthep Udomsawaengsup MD,Tracy Pitt DO,Bipan Chand MD,Philip R Schauer MD, The Cleveland Clinic Foundation

**BACKGROUND.** Morbid obesity is a low-grade chronic inflammatory disease that may be associated with specific immunological dysfunction. Studies on genetically obese rodent models have demonstrated improvement in immunological function with weight loss. In humans, the effect of surgically induced weight loss on the specific immune system has not been clearly elucidated. Our hypothesis is that surgically- induced weight loss enhances specific immunological functions. Analyzing lymphocyte and monocyte counts in bariatric patients who had lost weight following Laparoscopic Roux-en-Y gastric bypass and adjustable gastric banding tested this hypothesis.

**METHODS.** Patients who had undergone Laparoscopic Roux-en-Y-gastric bypass and adjustable gastric banding were selected. Those with signs of either infection or hematopathology were excluded. Pre- and post-operative complete blood counts (CBC with differentials) previously measured by standard hematological methods were analyzed for lymphocyte and monocyte counts and correlations with percentage excess weight loss (%EWL) determined.

The results were statistically analyzed using Student's t-test.

**RESULTS:** Eighty bariatric surgical patients were analyzed. Of these, 70 patients had undergone laparoscopic Roux-en-Y gastric bypass and 10 had laparoscopic adjustable gastric bypass.
banding. Cellular counts showed an upward trend with either decrease in BMI or increase percentage excess weight loss (%EWL). Lymphocyte counts increased by 30% to 40% and monocytes by 20-30% with EWL above 10%. The enhanced counts remained within standard normal ranges. The increase in the counts of these cells was not dependent on the length of time from surgery, but rather on the degree of weight loss alone. Trends in lymphocyte and monocyte counts were similar between procedure types.

**CONCLUSION:** The data are consistent with the viewpoint that surgically induced weight loss is associated with enhanced immunocompetence. Therefore, Laparoscopic Roux-en-Y gastric bypass and banding are not only weight loss operations, but also appear to be adaptive immune restorative procedures.

## Basic Science (cellular bio, physiology) - P140

**EFFECT OF BLOOD GAS CORRECTION ON TISSUE BLOOD FLOW DURING CARBON DIOXIDE PNEUMOPERITONEUM,** Yunus Yavuz MD, Kirsten Rønning, Jon Erik Grønbech, Ronald Mårvik, National Center for Advanced Laparoscopic Surgery, Department of Surgery, St. Olav's Hospital, 7006 Trondheim

**Background:** CO2 pneumoperitoneum induces an increase in partial pressure of CO2 (PaCO2) in the arterial blood unless corrected by ventilatory adjustments. The effect of usual level of CO2 pneumoperitoneum (i.e. 10-12 mmHg) on the tissue blood flow is known to be limited; however, little is known about what happens if hypercapnia is allowed. The aim of this study was to compare effect of blood gas correction on tissue blood flow in the intra- and extra-abdominal structures, in particular in the peritoneal tissue where the CO2 pneumoperitoneum induces a noticeable vasodilatation.

**Materials and Methods:** In a group of pigs (n=8), increase in PaCO2 was reversed by increasing tidal volume after induction of CO2 pneumoperitoneum of 10 mmHg (corrected group). In another group of pigs (n=8), blood gas correction was not attempted (uncorrected group). Tissue blood flow in various organs was measured at the basal level, 60th, 90th and 120th minutes by colored microsphere method.

**Results:** In the uncorrected group, CO2 pneumoperitoneum of 10 mmHg increased PaCO2 in arterial blood from a base level of 4.5-5 to 7 kPa (i.e. mild hypercapnia). Peritoneal blood flow increased significantly in both groups in all measurements. However, this increase was more prominent in the corrected group. Tissue blood flow in the central nervous tissue was increased in both corrected and uncorrected groups and it was significantly higher in the uncorrected group. The blood flow in the rest of the organs remained stable.

**Conclusion:** The increase in the peritoneal blood flow is a local effect of CO2 pneumoperitoneum, however increase in the blood flow in the central nervous is due to hypercapnia. Mild hypercapnia has a minor effect, if any, on tissue blood flow in most of the intra- and extra-abdominal organs.

## Colorectal/Intestinal Surgery - P141

**LAPAROSCOPIC MANAGEMENT OF COMPLICATED CROHN'S DISEASE,** Yaron Armon MD, Alex Mintz MD, Joseph Alberton MD, Petachia Reissman MD, Shaare-Zedek Medical Center, Jerusalem, Israel

**Introduction:** Crohn's Dis. in its complicated forms like large inflammatory mass, complex fistulae including entero-cutaneic/colonic or vesicle, extensive colonic disease, and recurrent disease in patients who had previous open resections presents a surgical challenge in both open and laparoscopic approaches.

**Aim:** to assess the feasibility safety and outcome of laparoscopy in complicated Crohn's dis. in a high volume IBD center.

**Patients and Methods:** Retrospective analysis of prospectively collected data of all consecutive patients who were defined as complicated disease based on the presence of a large inflammatory mass (>15cm) and/or complex fistulae.

All pts. were prepared with enteral or parenteral feeding, had a complete GI workup and had a laparoscopic assisted procedure.

**Results:** 45pts. (27M 18F, Age15-52, mean 28 y) were operated between 2002- 2006. Mean duration of dis. was 7y and 76% of pts. were on corticosteroids. 6pts. had a previous ileocolic resection. 37pts. had an inflammatory mass usually located in the RLQ or pelvis, 33pts. had 50 various fistulae including: 15 ileo-sigmoid, 11 ileo-ileal, 10 ileo-vesicle, 4 ileo-cutaneic, 3 ileo-cecal, 2 sigmo-vesicle, 2 ileo-transv. colon, 1 sigmo-cutaneic, 1 recto-vaginal, 1 ileo-vaginal. 86 procedures were performed in the 45pts. including: 31 ileo-colic resections, 13pts. had a total of 32 strictureplasties, 13 repair of sigmoid fistula, 10 SB resection, 10 urinary bladder repair, 4 segmental sigmoidectomy, 5 subtotal/total colectomy. 4pts.(8.8%) were converted due to the large inflam. mass and limited exposure. Mean OR time was 227 min(45-350), and length of stay - 9 days(5-23). Major morbidity of bleeding, leak and abscess occurred in 3pts.(6.6%,1 in each).

**Conclusions:** Disease severity in complicated Crohn's dis. commonly requires several procedures to be performed in each patient, and a relatively long hospital stay. However, despite of the technical challenges, laparoscopic management is feasible and safe in experienced centers.

## Colorectal/Intestinal Surgery - P142

**A COMPARISON OF HAND-ASSISTED LAPAROSCOPIC (HAL) AND LAPAROSCOPIC COLECTOMY FOR THE TREATMENT OF DIVERTICULAR DISEASE,** John M Aversa Jr DO, Andrea Ferrara MD, Paul R Williamson MD, Joseph T Gallagher MD, Samuel DeJesus MD, Alvaro Garcia MD, Colon and Rectal Clinic of Orlando

**Purpose:** Compare the clinical outcomes of HAL colectomy with conventional laparoscopic colectomy for patients with diverticular disease.

**Methods:** We reviewed our prospectively collected data base for laparoscopic surgery from 4/2002 to 8/2006 and extracted all consecutive cases that were performed for both acute and chronic diverticular disease.

**Results:** Fifty-nine surgeries were performed over the time period for both acute and chronic diverticulitis with and without abscess. Thirty cases were performed utilizing HAL approach and 29 were performed utilizing a conventional laparoscopic approach. Four of the 29 conventional laparoscopic cases were converted to open yielding a conversion rate of 14%. These converted cases were all complex in nature and their postoperative clinical data was excluded from further analysis. There were no conversions in the HAL group. The operation performed was sigmoid colectomy in a 95% of cases and LAR resection in the remaining 5%. Demographics were similar for both groups. In the HAL group 44% of patients were female and 56% were male with a mean age of 55.5(28-81). In the laparoscopic group 53% of patient were female 47% were male with a mean age of 51(39-68). BMI was 27.2 for the HAL group and 28.1 for the laparoscopic group. The HAL group had a proportionally higher percent of complicated cases 53% versus only 12% in the completed conventional laparoscopic group. There was no statistical significance between the two groups with regard to: length of stay, operative blood loss, time to clear liquid diet, time to flatus or use of post operative analgesics. There was a slight difference in operative time favoring the HALS group 200 min (127-237) compared with the conventional laparoscopic group 224 min (145-348) with p = 0.1. The complication rates were similar, 23% in the HAL group and 20% in the conventional laparoscopic group.

**Conclusion:** With regards to length of stay, return of bowel function and analgesic use HAL colectomy for diverticular disease appears to maintain the benefits of the conventional laparoscopic approach. In addition HAL approach extends the complexity of cases which can be completed utilizing a minimally invasive approach without compromising safety or lengthening operative time.
<figure><img src="image_92.png" /></figure>

# SAGES POSTER ABSTRACTS

## Colorectal/Intestinal Surgery - P143

SHORT-TERM RESULTS OF LAPAROSCOPIC SURGERY VERSUS OPEN SURGERY FOR RADICAL TREATMENT OF PATIENTS WITH COLORECTAL CANCER, Jeong-Heum Baek MD, Gil-Jae Lee MD, Jae Hwan Oh MD, Department of Surgery, Gil Medical Center, Gachon University of Medicine and Science

**Introduction:** The safety and oncologic outcomes of laparoscopic surgery for colorectal cancer remain controversial. The aims of this study are: (1) to assess the safety and the efficacy of laparoscopic colorectal surgery compared to those of conventional open surgery; and (2) to compare the disease-free survival (DFS) rates between laparoscopic and open colorectal surgery for radical treatment of patients with colorectal cancer. **Methods:** From January 2001 to December 2005, 583 patients underwent laparoscopic or conventional open surgery. To assess for radical surgery of colorectal cancer, we excluded subjects who had cases of emergency operations, conversion in laparoscopic surgery, stage IV cancer, or synchronous non-colorectal cancer. A total of 471 patients were enrolled for this study. The following parameters between the two groups were assessed: operation time, transfusion, days to flatus, length of distal margin, number of acquired lymph nodes, morbidity, mortality, and DFS rate. Survival data were analyzed using Kaplan-Meier curves. **Results:** There was no difference in the numbers of lymph nodes dissected nor in the lengths of the distal margins of the resected bowels of the laparoscopic group (LG) compared to the open group (OG) in colon cancer and rectal cancer, respectively (P>0.05). Also no difference was found in operation time, transfusion, days to flatus, hospital stay, postoperative complications such as bleeding, anastomosis leakage, ileus, and postoperative mortality (P>0.05). No significant difference was found in DFS rates of all stages and each stage (I, II, III) by comparing LG with OG in colon cancer and rectal cancer, respectively (P>0.05, Table).

<table><thead><tr><th></th><th>OG (n=169)</th><th>LG (n=62)</th><th>P value</th></tr></thead><tbody><tr><td>Colon cancer</td><td></td><td></td><td></td></tr><tr><td>5yr DFS (%)</td><td>77.6</td><td>90.2</td><td>0.255</td></tr><tr><td></td><td>OG (n=159)</td><td>LG (n=81)</td><td>P value</td></tr><tr><td>Rectal cancer</td><td></td><td></td><td></td></tr><tr><td>5 yr DFS (%)</td><td>68.8</td><td>84.6</td><td>0.348</td></tr></tbody></table>

**Conclusions:** The laparoscopic technique does not seem to present any disadvantages and this technique is safe and feasible for colorectal cancer. No difference was found between laparoscopic and open surgery in terms of short-term morbidity and DFS for colorectal cancer.

## Colorectal/Intestinal Surgery - P144

OUTCOME OF LAPAROSCOPIC COLORECTAL SURGERY IN OCTOGENARIANS, Carmen Balague PhD, Eduardo Targaron PhD, Pilar Hernandez MD, Carmen Martinez MD, Rodrigo Medrano MD, Juan Marin MD, Rene Berindoague PhD, Jorge Garriga PhD, Manuel Trias PhD, Hospital de la Sta. Creu i St. Pau

Patients over 80 years are increasing. Open colorectal surgery in these patients is associated with increased morbidity. Laparoscopic colorectal resection (LCR) can be done safely. However, the surgical outcomes are not enough documented.

**Aim:** To evaluate the surgical outcomes of LCR in a prospective serie of 112 patients older than 80 years diagnosed of colorectal cancer. **Material & methods:** Jan/98-Febr/06.

Performed 507 laparoscopic resections for colorectal cancer. **Data prospectively recorded.** Patients divided in 3 groups of age: Group I: <70 years, Group II: 70-79 years and Group III: over 80 years. We compare the results.

**Results:**

**Table I:** Surgical and postoperative results
Group I Group II Group III
n 210185112
Mean age 607584
Sex (m-f) 120 - 90 126 - 5961 - 51
Comorbidity 36%55%47%
Previous surgery 29%39%43%
T4 19%21%13%
Operative time 152152148
Perop complications 30%32%30%
Conversion 15%18%20%
Postop complications32% 33%34%
Anastomotic leakage4% 6% 3%
Hospital stay (d.) 789
Reoperation 2% 9% 3.5%
Mortality 0.5% 2.7% 1%

**Table II:** Procedures
Group IGroup IIGroup III
Right col 42 (20%) 61(33%) 36 (32%)
Left col 13 (6%) 16(9%) 4 (3%)
Sigma res 72 (34%) 50(27%) 28(25%)
anterior res 49 (23%) 34 (18%) 20 (18%)
APR 26 (12%) 19 (10%) 14 (12.5%)
Colectomy27 (12%) 0 (0%) 1 (0.8%)
Hartmann 28 (12%) 4 (2%) 7 (6%)
Palliat treat 29 (12%) 1 (0.5%) 2 (1.7%)

**Conclusion:** Laparoscopic colorectal resection is safe and feasible in elderly patients. Postoperative recovery and quality of life have to be evaluated

## Colorectal/Intestinal Surgery - P145

INTRAOPERATIVE GAMMA PROBE LOCALIZATION OF THE URETERS: A NOVEL TECHNIQUE, Todd Berland MD, S L Smith MD, P P Metzger MD, K L Nelson PhD, G P Fakhre MD, H K Chua MD, O L Burnett MD, J Falkensammer MD, H J Hickman DO, R A Hinder MD, Mayo Clinic Jacksonville

**INTRODUCTION:** Localizing the ureters during surgery can be a challenging task. Ureteral stent placement, currently the gold standard, is an invasive procedure. The aim of this study was to evaluate the feasibility of using the gamma probe to intraoperatively identify the ureters after an intravenous injection of a radiopharmaceutical. If gamma probe localization of the ureters is possible, the need for ureteral stent placement could be obviated. This concept has never before been described, and offers a non-invasive alternative to ureteral stenting.

**METHODS:** 10 patients (6 male, 4 female) undergoing elective, abdominal surgery were prospectively enrolled in this study. The mean age was 51.9 years (range 30 - 71 years). An average dose of 4.5 mCi (range 2.8 - 5.3 mCi) of technetium-99m labeled diethylene-triamine-penta acetate (Tc-DTPA) was administered intravenously prior to localization of the ureters. The gamma probe was used to localize the ureter, and the correct identification of the ureters was confirmed when gentle manipulation induced the typical ureteral peris

**RESULTS:** Gamma counts were significantly elevated in all ureters examined. When compared to background counts, increased gamma counts were present over the ureter in all patients with an average increase of 465%. The technique was modified after being used in the first three patients and was standardized for patients 4 through 10. Data from those patients were analyzed. After a single injection of Tc-DTPA, the gamma probe was used in two patients at two different times during the operation to further define the temporal limitations of this technique. Both ureters could be correctly identified using the gamma probe at a mean of 15 minutes (median=10 minutes) after a single Tc-DTPA injection. (range 4 - 41 minutes). The mean background count was 80 (range 50 - 130). The mean ureter count was 393 (range 128 - 700). The average percent increase of each ureter count to its specific background count was 465% (range 256%-1077%). The difference was statistically significant for all values (p < 0.001).