LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS USING 3 PORTS TECHNIQUE FOR TREATMENT OF MORBID OBESITY

1

Surgery Department, Riyadh Military Hospital, Riyadh, Saudi Arabia

Haider Alshurafa1

LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS USING 3 PORTS TECHNIQUE FOR TREATMENT OF MORBID OBESITY Haider
A Al-Shurafa , Riyadh Military Hospital, Riyadh, Saudi ArabiaObjectives:To present the technique andthe results of laparoscopic Roux-en-Y gastric bypass (LRYGBP) using 3 ports technique for the treatmentof the morbid obesity.Method and Materials:This is a retrospective review of the medical records forthe patients who have underwent LRYGBP using 3 ports technique and were operated by the first author
in Riyadh Military Hospital, Riyadh, Saudi Arabia.Results:In the period from April 2004 to December 2008,
37 patients, out of 343 patients have LRYGBP, have underwent LRYGBP using 3 ports technique. They were
26 females and 11 males. The age was 28 years (15-52 years). The body mass index was 42.4 kg/m2 (35 54 kg/m2). The average time of the operation was 70 minutes. The hospital stay was 1-3 days. There was
one patient who had immediate postoperative hematemesis which was stopped spontaneously. One patientneeds abdominal drain for 24 hours. There was no other major complications and no mortality. All of thesepatients were primary LRYGBP without history of previous abdominal surgeries.ConclusionLRYGBP using 3
ports technique is feasible and safe procedure for treatment of morbid obesity although it needs extensive
experience in laparoscopic and bariatric surgeries.

Single Incision Laparoscopic Adjustable Gastric Band: Early Results Incorporating New Techniques

1

Castle Medical Center

Steven Fowler1

Background: Single Incision Laparoscopic Surgery (SILS) is rapidly being developed in the use of bariatricprocedures, such as the Adjustable Gastric Band (GB).
Methods: In November 2009, SILS GB was initiated in a single surgeon practice, United States Centersof Excellence Bariatric Surgery Program. One year of data was collected. A comparative group of standard
5 port laparoscopic GB from the year prior was used as a benchmark.
Results: 58 SILS GB were performed from November 2009 to November 2010. 75 standard GB were performed
the year prior. Average operating time was 70 versus 43 minutes. Complication rate for SILS GB was 5.2%
versus 4%, consisting of two early band slips and one port infection. 1 month, 3 month, and 6 month %Excess
Weight Loss was 13.5% versus 14.1%, 24.4% versus 23.7%, and 29.2% versus 30.4%. With the SILS GB, adding
an extra port occurred 41% and adding improved liver retraction occurred 33%.
Conclusions: SILS GB requires greater operating time. Early weight loss appears comparable to standard
GB. This type of surgery allows for easy adjustments in technique by adding ports or liver retractors
to account for limitations in instrument design and body habitus.

SILS Bariatric Surgery for animal model1

Department of Gastrointestinal surgery, Nagoya City University, Nagoya, Japan

Satoru Takayama1,Masaki Sakamoto1,Hiromitsu Takeyama1

Laparoscopic metabolic surgery was developed through the application and experienced mainly in westerncountries. And it is also spreading in Asian countries. Meanwhile Single-incision laparoscopic surgery
is aimed at improving the cosmetic outcome following surgery appears now a day. Much of this knowledge
from the procedures comes from the study of animal models, where they have revealed technical feasibility.
This time we have experienced three kinds of SILS bariatric surgeries for animal models. The first one
was the gastric banding, the second one was the sleeve gastrectomy and the third one is ρ-Y bypass.
All of these cases, we placed SILS port near umbilicus at the beginning of surgery and used flexible
forceps. In case of gastric banding, we used flexible SILS Stitch, and in case of sleeve gastrectomy
we used Duet which is also flexible to avoid interference of forceps. And the bypass case, we used V-Loc
suture to free from the stress of knotting. Using such new methods, we have successfully performed thesebariatric surgeries. It is true that this methodology need experienced technique and need more time thanconventional multi incisional surgery. But we believe we can make the operative time shorter and improves
cosmetic outcome without additional risk even for human SILS bariatric surgery. This methodology may
be applied widely for human as the option for new bariatric surgeries in near future. Thereby we would
like to introduce these experiences.

Single-incision laparoscopic gastric bypass for morbid obesity-Using conventional trocars andinstruments

1

Department of Baritric and Metabolic Surgery,Gem Hospital and Research Centre,

Praveen Raj1,c Palanivelu1

Abstract:Conventional laparoscopic Roux-en-Y gastric bypass (LRYGB) is gold standard for bariatricsurgery, but the procedure requires five to seven incisions for placement of multiple trocars and thus
may produce less-than-ideal cosmetic results. Recently, single-incision laparoscopic surgery (SILS) has
been used for bariatric procedures, and this surgery is considered a type of minimally invasive surgery.
When SILS is performed via the transumbilical route, the resultant abdominal wound is hidden and thecosmetic outcome is better.Here we present one of our cases of Single Incision transumbilical Roux en
Y gastric bypass Surgery without usage of any commercially available single port systemsVideo:In thishigh Definition video, we show a single incision Laparoscopic Roux en Y gastric bypass.-Step 1 involves
creating a transverse umbilical scar and raising umbilical flaps on either side-Four trocars (12mm, two
5mm and one 10mm) are inserted directly through the fascia at different sites after creating thepneumoperitoneum-the liver was retracted using a novel liver suspension technique of passing prolene
suture through the liver and suspending the liver using gauze -The gastric pouch of 50ml is created instandard fashion using blue cartridges-the gastrocolicomentum is divided in the midline-the jejunum

was divided at 75 cm and the jejuno-jejunostomy was done with 100cm Roux limb using linear staplers andintracorporeal sutures-The gastrojejunostomy was performed using 35mm liner staplers and the defectclosed with 2-0 PDS with intracorporeal suturingRetrospective analysis from 99 Japanese cases of bariatric surgery at Chiba University Hospital.

1

Research Center for Frontier Medical Engineering, Chiba University, Chiba, Japan 2Frontier Surgery, Chiba

University Graduate School of Medicine, Chiba, Japan 3Department of Surgery, Shimotsuga General Hospital,
Tochigi, Japan
Hiroshi Kawahira1,Isao Kawamura2,Masaaki Kodama3,Hideki Hayashi1,Toshiyuki Natsume2,Takashi Akai2,Mikito
Mori2,Yukimasa Miyazawa2,Hisahiro Matsubara2

Background: Since "classical-style" gastric bypass for morbid obesity has been performed in 1982, thefirst bariatric surgery in Japan, the number of obesity patients has been gradually increased. This is
the retrospective analysis of the patient outcome at Chiba University Hospital, Japan. Patients & Methods:
99 patients have been operated for bariatric surgery in our department and our related hospital from1982 though 2006. 31 males and 68 females were applied. The average age was 30.7 ± 9.8 years. 11 classicalstyle gastric bypass, 69 gastroplasty (50 vertical banded gastroplasty, 8 horizontal banded gastroplasty,
11 other types), 17 Roux-Y gastric bypass, 1 sleeve gastrectomy and 1 sleeve gastrectomy with duodenalswitch were performed in this study. Results: The body weight of each patients has been decreased favorably(figure). Among all surgery, no postoperative death has been observed. Conclusion: Our results indicatedthat bariatric surgery is safe and effective for Japanese.

Although the higher disease rate of gastriccancer than western patients, we expect that more clinical trials will be designed and performed formore effective and suitable surgical procedures for Japanese obesity patients.

Similar resolution of weight and biochemical aberrations in the first 24 months despite different
bariatric procedures

1

Nutrition Course,

N.S.Fatima Faculty and University of Sao Paulo, Brazil 2Nutrition Course,

N.S.Fatima

Faculty, Caxias do Sul, RS, Brazil
Joel

Faintuch2,Daniela

Giesch2,Camile

2

2

Soares ,Francisco J Karkow

Boscaini2,Lovaine

Rodrigues2,Fernanda

Pezzi2,Rafael

M

Introduction: Malabsorptive operations (Scopinaro/SCOP and duodenal switch/DS) are considered more
effective than Roux-en-Y gastric bypass (RYGB) for weight reduction and biochemical normalization, but
comparative studies are not common . Objective: In a single-center prospective study, outcome in thefirst two years was comparatively monitored. Methods: Patients (N=41) were submitted to threeinterventions (SCOP, DS and RYGB) according to clinical criteria. There were no differences regarding
age ( 44 &plusmn 11 years), gender ( 83% females) or preoperative BMI or body weight (BMI 46 &plusmn
5 kg/m2).

Measurements included hematologic counts, iron, ferritin, triglycerides, total cholesteroland fractions, and glucose., which were documented preoperatively and

1, 3, 6, 12 and 24 months after

surgery.Results: Patients submitted to the Scopinaro modality exhibited higher preoperative BMI (notstatistically significant), but difference leveled off after 12 months. By the same token most biochemicalvariables normalized between 6 and 12 months, so that after two years the three populations displayed
similar numbers for all documented variables. Conclusions: All three techniques were followed by adequate
clinical and biochemical response. Scopinaro candidates were somewhat heavier but reached comparable
BMI at the end of the study. Differences between the operations were not obvious during 24 months, andshould probably require longer follow-up and superobese participants to be detected.

Intragastric balloon treatment for morbid obesity in Japanese patients.

1: Department of Gastrointestinal Surgery, Graduated School of Medicine, The University of Tokyo
2: Department of Gastrointestinal Surgery, Toranomon Hospital
Fumihiko Hatao1, Masako Ogawa1,2, Yumie Wada1, Nobuyuki Shimizu1, Yasuyuki Seto1

Background; Recently, also in Japan, bariatric surgery is a growing trend. We concern that Japanesepatients undergoing bariatric surgery are at risk of developing gastric cancer, which is the most common
malignancy in Japanese. Therefore, we expect that the temporary placement of intragastric balloon issuitable for Japanese.
Methods; We started the clinical trial of intragastric balloon treatment from 2007. We picked up patients
according to the inclusion criteria of our institution which was “morbid obesity (BMI ≧ 35) after
conservative treatments including admission of more than one week duration and outpatient visit for 6
months.”The balloon was removed within 6 months according to the manufacturer's suggestions.

Results; Six patients who met this criteria underwent the placement of intragastric balloon. No
complications occurred. The average duration of procedure was 20.8 min. The average length of the hospital
stay was 6.0 days. No one needed to remove ahead of schedule. The average weight loss and percent excess
weight loss at the time the balloon was removed were 10.4 kg and 19.8%, respectively. Four patients had
kept more than 20% of percent excess weight loss 6 months after the balloon removal. However, 2 patientsalready regained their weight during the placement of intragastric balloon.
Conclusion; Intragastric balloon treatment for morbid obesity in Japanese patients is safety and havesome efficacy.

Intragastric balloon treatment for morbid obesity in Japanese patients.

Fumihiko Hatao1, Masako Ogawa1,2, Yumie Wada1, Nobuyuki Shimizu1, Yasuyuki Seto1
1: Department of Gastrointestinal Surgery, Graduated School of Medicine, The University of Tokyo
2: Department of Gastrointestinal Surgery, Toranomon Hospital

Background; Recently, also in Japan, bariatric surgery is a growing trend. We concern that Japanesepatients undergoing bariatric surgery are at risk of developing gastric cancer, which is the most common
malignancy in Japanese. Therefore, we expect that the temporary placement of intragastric balloon issuitable for Japanese.
Methods; We started the clinical trial of intragastric balloon treatment from 2007. We picked up patients
according to the inclusion criteria of our institution which was “morbid obesity (BMI ≧ 35) after
conservative treatments including admission of more than one week duration and outpatient visit for 6
months.”The balloon was removed within 6 months according to the manufacturer's suggestions.

Results; Six patients who met this criteria underwent the placement of intragastric balloon. No
complications occurred. The average duration of procedure was 20.8 min. The average length of the hospital
stay was 6.0 days. No one needed to remove ahead of schedule. The average weight loss and percent excess
weight loss at the time the balloon was removed were 10.4 kg and 19.8%, respectively. Four patients had
kept more than 20% of percent excess weight loss 6 months after the balloon removal. However, 2 patientsalready regained their weight during the placement of intragastric balloon.
Conclusion; Intragastric balloon treatment for morbid obesity in Japanese patients is safety and havesome efficacy.

Gastric Sleeve is a single restrictive procedure?

1

Clinica Universitaria de Cirurgia 2, Hospital de Santa Maria / Faculdade de Medicina de Lisboa, Lisboa,

Portugal
Joao M. Coutinho1,Fatima M. Carepa1,Jose S. Girao1,Carlos M. Ferreira1,Helena P. Proenca1,Carla M.
Melo1,Guilhermina C. Cantinho1,Henrique B. Castelo1

The authors present in their 221 gastric sleeve patients the criteria in which they consider gastricsleeve is both a metabolic and restrictive procedure.The improvement of the associated diseases, visceralfat, BMI and EWL, the levels of grelin, obstatin, grelin/obstatin ratio, PP-YY, the gastric emptying
before and after surgery, are evaluated in this series two years after surgery to demonstrate both
metabolic and restrictive features of this procedure.

GASTRIC SLEEVE AS TREATMENT FOR MORBID OBESITY: ANALYSIS OF 3 YEARS

1Clinica Universitaria de Cirurgia 2, Hospital de Santa Maria / Faculdade de Medicina de Lisboa, Lisboa,

Portugal
Joao M. Coutinho1,Fatima M. Carepa1,Jose S. Girao1,Carlos M. Ferreira1,Dulce A. Antunes1,Mariana M.
Machado1,Filipa A. Andrade1,Helena P. Proenca1,Antonio F. Fernandes1,Henrique B. Castelo1

The authors analyze the results of their series of GASTRIC SLEEVES as treatment of patients with morbid
obesity.The study includes 221 patients evaluated at outpatient follow-up during two years of post-op,
according to the following protocol:Clinical Assessment, % of weight loss, decreased BMI and%
EWL;-Evolution of co-morbidities;Determination of ghrelin pre-and post-operative, as well as therelationship ghrelin / obestatin;Changes in gastric emptying, compared to pre-operative, 3, 6, 12 and24 months.The Authors also examine morbidity and mortality in the series.

Laparoscopic Adjustable Gastric Banding: 7-year results in Taiwan

1

Department of Surgery, Min-Sheng General Hospital

YEN HAO SU1,WEE JEI LEE1,KUANG HAN

SER1,JUNG CHIE CHEN1,SHU CHUN CHEN1,YI CHIH LEE1

Objectives: Laparoscopic adjustable gastric banding (LAGB) is a pure restrictive bariatric surgery. We
had reported our short-term results of LAGB in Taiwan. In this study, we report the long-term resultsof LAGB in Taiwan. Materials and Methods: From January 2002 to June 2010, 246 consecutive patients withmorbid obesity underwent LAGB in our department. Mean age was 32.1 years and mean BMI 39.8 Kg/m2.

The

demographic data and post-operative results were recorded . Results: All procedures were performed
laparoscopically with no conversion to open surgery.The major and minor complication-rate was 0% and
3% respectively. Mean BMI from 39.8 Kg/m2 to 35.4, 36.3, 34, 33 ,31 ,30.7 and 32.6 at 1, 2, 3, 4,5,6
and 7 years respectively, with 80% follow-up.

Revision rate was 13% (33/246). The most common causeof revision bariatric surgery was failed to lose adequate weight (20/32, 62.5%), poor quality of life
(5/32, 15.6%), and band slippage (3/32, 9.3%).Conclusion: LAGB is safe and effective in weight reduction
and improvement of quality of life. However, a late surgical re-intervention rate of 13% was observedwith conversion to another bariatric procedure was 8%.

The experience of laparoscopic mini-gastric bypass surgery in single institute of sunthern Taiwan.

1

Department of Surgery, National Cheng Kung University Hospita, Tainan, Taiwanl 2Min-Sheng General

Hospital
Kuo-Ting Lee1,Wei-Jei Lee2Introduction: Gastric bypass surgery is an effective treatment for morbidly obese patients. In Taiwan,
the incidence of morbid obesity increases. More obese patients would have bariatric surgery. We presented
the clinical results of laparoscopic mini-gastric bypass surgery in our hospital. Method and Material:
From 14,Jan,2009 to 17,Nov,2010, there were thirty patients underwent bariatric surgery in National Cheng
Kung University Hopital. Twenty-three patients (12 women,11 men) underwent mini-gastric bypass surgery.
Mean Body mass index (BMI) was 39.8 (30.7-55.7). All the procedures were completed laparoscopically .
No conversion procedure occured. We retrospectively analyze the patients' clinical data andoutcomes.Results: All patients had weight loss after surgery. Two patients had post-operativecomplications. One female patient had pituitary tumor hemorrhage 4 days after surgery. Later she had
craniotomy, and recovered. She had the hospitsal stay 25 days. Two months later, she totally recovered.
Another female patient had post-operative upper gastrointestinal hemorrhage imediately after surgery.
She had the conservative treatment. The bleeding stopped one day later. One female was dead 25 days after
surgery because of acute respiratory distress syndrome. The mean hospital stay was 6.4 days. All thepatients had regular follow-up visit in our hospital. Conclusion: The laparoscopic mini-gastric bypass
surgery could have an ideal body weight reduction, and it is a feasible surgery for morbidly obese patientsin southern Taiwan.

The introduction of laparoscopic sleeve gastrecotmy: initial three clinical experiences

1

The Department of Gastroenterological Surgery, University of Osaka, Osaka, Japan

Yasuhiro

Miyazaki1,Shuji

Takiguchi1,Kiyokazu

Nakajima1,Yukinori

Kurokawa1,Hiroshi

Miyata1,Makoto

Yamasaki1,Yoshiyuki Fujiwara1,Masaki Mori1,Yuichiro Doki1

Introduction: Recently, Sleeve gastrectomy(SG) has been proposed as potential single restrictive
baratric procedure. In fact, clinical outcome in terms of weight loss and resolution of comorbidities
encouraged and stimulated the diffusion of SG as a primary bariatric procedure. Based on the above,
laparoscopic sleeve gastrectomy (LSG) was introduced for primary procedure for morbid obesity in our
institution. The objective of this study was to evaluate the feasibility and safety of LSG at the timeof introduction for initial three cases. Objectives: LSG was introduced in our institution in March 2010
and performed in 3 patients (1 male, 2 females). Case 1: 26 year-old male, BMI48.1kg/m2, his comorbidities
with obesity were insulin dependent diabetes mellitus (DM), hyperlipemia, fatty liver, insomnia, andsleep apnea syndrome, Case2: 24 year-old woman, BMI44.1kg/m2, with slight mental retardation, and hercomorbidities were right cardiac failure and pulmonary hypertension, Case 3: 43 year-old woman, BMI44.3
kg/m2, with psychiatric disorder, and her comorbidities were the same as case 1.Results: LSG was completed
in 3 patients without conversion to laparotmy. Each operating time(minutes) was 150, 250, 176 andestimated blood loss(ml) was 20, 540,30, respectively. No major postoperative complications directly
related to LSG were noted. All patients showed uneventful postoperative recovery, with their oral intake
resumed in 2 days and median hospital stay of 15days. They showed expected effect on body weight loss,
and remarkable improvement of DM in case 1 and 3 resulted in no need for insulin injection. Conclusion:
LSG was safely introduced as primary procedure for morbid obesity in our institution.

Sleeve Gastrectomy in combination with Duodeno-Jejunal Bypass. Three year Period Results.

1

State Hospital, Ufa, Russia 2Bashkirian University of Medecine

Evgeny E Semenov1

Background: A new surgical procedure - Sleeve gastrectomy with Roux-en-Y Duodeno-Jejunal bypass (SG-DJBP)
is being performed in the world since 2007. They generally brought to successful results but some certain
indications to the operation might be developed.
Material and methods: We present results of four SG-DJBP procedures performed since July 2007 to September
2010. The mean age of patients was 38,1±7,3 (29-48) years, mean BMI-47.4±7,8kg/m2(38,9-59,8), initial
weight-130,6±22,6kg (111-159). A Roux-en-Y procedure was performed with a biliopancreatic loop 60 cm
and alimentary loop-100 or 150 cm depending on initial BMI (less or more 50 kg/m2 respectively) four
operations within a period of follow up control for 3 years and ±6 months. Two operation were performed
with alimentary loop-180 with the follow up control up to 1 year. A bandage was placed on the gastrictube intersurgically to two patients.
Results: All the patients tolerated the procedure well. During 6 months the percentage of %EWL was 45,7
±5,1%. Up to 1 year all the patients could lose more than 53,2 %EWL (47,0 - 64,4%). Up to 3 years 4
patients could lose more than 60,7% EWL (52,6 - 68,6%). The patient with a bandage had the best result- 68,6%. All the patients have a tendency to further weight gaining up to 3-8kg.
Conclusion: The positive influence on the carbohydrate and lipid metabolism is noticed, all the patients
have a slight weight gaining, but there is a less weight gaining with a bandage. It is connected withthe stomach extension and lesser malabsorption in contrast to BPD, a bandage gives additional restriction.
SG-DJBP is an effective and safe surgery with the slightest metabolic disturbances. It might be offeredto patients with BMI>50kg/m2. However, it is necessary to control a follow up period and compare it withthose of SG and BPD.

A case of migration of gastric band

1

Clinica Universitaria de Cirurgia 2, Hospital de Santa Maria / Faculdade de Medicina de Lisboa, Lisboa,

Portugal
Joao M. Coutinho1,Andreia C. Barao1,Jose S. Girao1,Fatima M. Carepa1,Ines L. Leite1,Graciela M.
Matias1,Antonio F. Fernandes1,Antonio S. Ruivo1,Henrique B.

Castelo1

Bariatric operations produce weight loss as a result of two factors. One is restriction of oral intake.
The other is malabsorption of ingested food. All bands work on the principle of restriction of oral intake
by limiting the volume of the proximal part of the stomach. Their major advantage is adjustability. Their
most common complications include acute obstruction of the stoma, infection, prolapse of the band,
attached to the trocar ports and erosion / migration of the band, which is a rare complication (3%).TheAA present a case of migration of gastric band, four years after his placement in a patient with morbid
obesity, which starts with dyspepsia, nausea and fever and whose imaging and endoscopic study revealed
migration of the band with gastric fistula.

Endoluminal Surgery (StomaphyX device). An alternative to the revision surgery?

1

Clinica Universitaria de Cirurgia 2, Hospital de Santa Maria / Faculdade de Medicina de Lisboa, Lisboa,

Portugal
Joao M. Coutinho1,Jose S. Girao1,Fatima M. Carepa1,Adreia C. Barao1,Elisabete S. Ferreira1,Carlos S.
Silva1,Graciela M. Matias1,Antonio S. Fernandes1,Henrique B.

Castelo1

The Authors analyze the results of Endoluminal Gastroplasty "StomaphyX" obese patients already receiving
prior to bariatric surgery.The 15 patients in whom technique was used, 4 had previously undergone gastricSleeve, 10 gastric bypass and 1 placement of a gastric band. All patients remained liquid diet / paste
for 3 months postoperatively and were evaluated by Esophagogastroduodenoscopy at 6 months, confirming
the maintenance of fasteners. We evaluated the weight loss at 1, 3 and 6 months of surgery as well as
the improvement the feeling of satiety reported by all patients pre-application of the technique.The
Authors conclude the benefits of endoluminal gastroplasty and advantages of this technique which canbe used repeatedly in the same patient.

A successful case of safety weight loss using formula diet in alcoholic cardiomyopathy with obesity

1

Internal medicine, Toho University Sakura Medical Center, Chiba, Japan

HiroshiMikamo1,Kazuhiro

Shimizu1,Keiichi

Hirano1,Kakahiro

Nakagami1,Masayo

Suzuki1,Mao

Takahashi1,Takuo Iiduka1,Yuukou Sugiyama1,Hirohumi Noike1,Kouji Shirai1

Introduction: We often experiences weight loss improve cardiac function in obesity with heart failure(HF). Recent study shows obesity may lead to left ventricular hypertrophy and systolic dysfunction. On
the other hand, alcoholic cardiomyopathy is a common cause of DCM-like change. Alcohol effect on cardiac
function can usually be reversible by abstinence from alcohol. Since alcohol addict often are complicatedwith metabolic syndrome, they should be treated comprehensively. Therefore, it is important to reduceweight of these patients. So, modern formula diet has been recommended as dietotherapy. However there
are few reports on the use of formula diet for them. Previous report showed healthy obese patients diedsuddenly during use of the liquid-protein-modified-fast diet 30years ago. The cardiac accident appears
to depend on diet duration and on whether protein and mineral nutritional status are maintained.
Pronounced weight loss causing lack of these nutrients has been thought to produce a decrease in myocardial
fiber size. However, the moderate caloric restriction could be performed enough safely by the modern
formula diet including protein, vitamins, a mineral. We report a case of weight loss using formula dietafter acute heart failure (AHF) treatment. Case report: 36-year-old obese male was hospitalized withdyspnea. On admission, his weight was 103.3kg, BMI 32.6kg/m2. Blood pressure was extremely high.
Examinations revealed severe cardiac dysfunction, enlarged heart and pulmonary congestion. He had aten-year history of alcohol abuse. As above, AHF due to alcoholic cardiomyopathy with obesity andhypertension was diagnosed according to the absence of coronary disease. After AHF therapy, weight loss
using formula diet and cardiac rehabilitation were started. After these therapies, weight was reduced
to 82kg. The cardiac function was improved without any cardiac accident during the hospital days.
Conclusion: Weight loss using the formula diet for obese patient with HF was safe and useful.

Gastric Sleeve and Metabolic Syndrome1

Clinica Universitaria de Cirurgia 2, Hospital de Santa Maria / Faculdade de Medicina de Lisboa, Lisboa,

Portugal
Joao M. Coutinho1,Fatima M. Carepa1,Jose S. Girao1,Carlos M. Ferreira1,Helena C. Pinto1,Henrique B.
Castelo1

The Metabolic Syndrome (MS) is a complex disease, associated with an increased cardiovascular risk, due
to central fat distribution and insulin resistance. Today there are several treatments for MS, including
bariatric surgery, that improve that cardiovascular risk.The authors present a group of 48 patients withMS, submitted to gastric sleeve procedure,and evaluate their BMI, body weight and MS at 6, 9 and 12

months after surgery. The MS improved with weight loss in all the patients, sometimes with fullremission.The authors conclude that gastric sleeve surgery is a good option for the treatment of MS inobese patients.

Our experience in treatment of metabolic syndrome

1

Faculty Surgery Clinic, State Medical University n.a. Pavlov, Saint-Petersburg , Russia

Michael B. Fishman1,Valery Sedov1

Methods. A total of 439 patients underwent various bariatric procedures for 9 years were investigated.
In 391 cases laparoscopic operations were done. LAGB was performed in 307 patients. Median age was 37.
There were 253 (82,4%) women and 54 (17,6%) men. Average preoperative BMI was 42 kg/m2 (35 to 54). Beginningfrom 2007 we had performed 45 patients underwent LSG, 11 - LDS, 28 - LRYGB. Median age for the patientswas 36 years, of them 63 (75%) were females and 21 (25%) males. BMI was in limits of 41-90 kg/m2. In
the cohort of patients who underwent LAGB 68 (22,4%) suffered from metabolic syndrome (MS), LSG - 12
(26,6%),LDS - 100%, LRYGB - 16 (57,1%) respectively.Results. At North-West Russia obesity was foundin 41,4%. After LAGB during first two years of follow up sugar level in blood became normal in 156 (52,3%)
patients. Blood pressure became normal in 103 (34,5%). BMI was in limits of 26 - 38 kg/m2 with the sametendency in the following years. We managed best weight reduction mainly in women younger then 39 y.
o., with BMI lower then 45 kg/m2. In 46 (15,4%) patients there were complications, among them 38 (12,7%)
cases of bandage slippage. 17% of the patients were reoperated. Symptom-complex, that different MS was
lost after LDS in 100 % and in 75% after LRYGB. No complications were identified after LSG, LDS and LRYGB.
Conclusion. LAGB is an effective method of treatment for the patients with BMI lower then 45 kg/m2 inyounger age cohort. LSG can be an alternative for LAGB.LDS and LRYGB are most effective operations intreatment of MS.

Irregular CPAP use induced visceral fat accumulation in obstructive sleep apnea regardless of daily
sleepiness

1

Department of Cardiovascular Center, Sakura Hospital, Medical Center, Toho University, Chiba, Japan2

Department of internal medicine, Sakura Hospital, Medical Center, Toho University Chiba, Japan3

Department of ophthalmology, Sakura Hospital, Medical Center, Toho University Chiba

mao takahashi1,takashi hitsumoto2,tomoaki shiba3,kohji shirai2

Background: Obstructive sleep apnea syndrome (OSAS) is a common disorder in obese subjects. Occasionally
OSAS causes excessive daily sleepiness (EDS) and resulted in adipose tissue accumulation. The other hand,
there were many people who do not have daily sleepiness despite of sever OSAS. But the effect of continuous
positive airway pressure (CPAP) treatment on visceral fat accumulation (VFA) in OSAS without sleepinesshas not been known.

Material and Methods:VFA and subcutaneous fat accumulation (SFA) were assessed by CT before and 1 year
after CPAP treatment in 47 OSAS patients(mean apnea and hypopnea index/Epworth sleepiness scale;40.7
times/h/5.4±4.5).The sample was divided according to CPAP therapy, with regular users defined as aminimum nightly use of(≥4 h /day≥75%/month);27 subjects were regular and 20 were irregular CPAP users.

Results: Neither the regular CPAP use group nor irregular CPAP use group showed any change in body massindex or subcutaneous fat area levels.VFA increased significantly after 1year of CPAP treatment in
irregular user(171.3±68.5 to 161.2±72.4cm2 (-3.4±5.1%) vs 170.0±75.3 to 192.5±66.7cm2 (+13.4±
14.6%), P<0.0061)

ConclusionsThese data suggested that irregular CPAP use induce visceral fat accumulation in patientswith severe OSAS regardless of EDS. OSAS may have significant effects on the visceral fat accumulation
without EDS.

Individualized intervention with Metabolic Stem Cell system after bariatric surgery

1

Department of Complementary & Alternative Medicine, Osaka University Graduate School of Medicine

2

Department of Metabolic Medicine, Osaka University Graduate School of Medicine

3

Department of

Gastroenterological Surgery, Osaka University Graduate School of Medicine
Miki Sakaue1,Kazuhisa Maeda1,2,Kei Hirai1,Yasuhiro Miyazaki3,Shuji Takiguchi3,Yuichiro Doki3,Toshinori
Ito1,3(Background) In addition to reducing body weight, ameliorating fat dysfunction by improving
hypoadiponectinemia is crucial in protection against the development of metabolic syndrome. We recently
started a Weight Management Clinic in order to perform integrated and individualized intervention forobese patients. Here we report 3 cases whose metabolic stem (MSC) cell as adipocyte precursors wereobtained during bariatric surgery that can be used as a novel screening system for selecting
patient-suitable drugs or supplements to enhance adiponectin secretion. (Method) MSC were prepared fromfat tissues collected from 3 patients during bariatric surgery. Case1: 24yo male BMI 52 adiponectin
3.5ug/ml Case2: 24yo female BMI 46 adiponectin 5.3ug/mlCase3: 40yo female BMI 40 adiponectin 1.7ug/mlMSCs
were differentiated in cultures into mature adipocytes and treated with drug or supplementation medium
every 48 hours. Levels of adiponectin were measured in the culture medium. Dividing the adiponectin
secretion on day 12 by that on day 10 provided an estimate of adiponectin-producing activity in culture.
(Result) Using this score, we assessed 80 candidate agents in a 96-well plate. Moreover, we identified
some novel adiponectin up-regulatory effects for several substances, including Turmeric and Ryukyu herb.
Even after weight reduction achieved by surgery, additional enhancement of adiponectin was observed in
all cases with suitable supplementation. (Case1: adiponectin 7.4 ug/ml, Case2: adiponectin 10.1 ug/ml,
Case3: adiponectin 2.1ug/ml)(Conclusion) MSC system is able to identify potential responders to specificagents. This can be applied to post-operative individualized intervention for morbid obese patients.

Diabetic complications stratified by past maximum body mass index

1Center of Diabetes, Endocrine and Metabolism, Toho University Sakura Medical Center 2Department ofInternal Medicine, Toho University Sakura Medical Center
Takashi Yamaguchi1,Atsuhito Saiki1,Noriko Ban1,Hidetoshi Kawana1,Daiji Nagayama1,Ayako Nagumo1,Masahiro
Ohira1,Kei Endo1,Tomokazu Oyama1,Yoh Miyashita1,Kohji Shirai2

Background: In Japan, prevalence of obesity (especially high degree obesity values 35<BMI) is relatively
low. Therefore, relationship between degree of obesity and development of diabetic complications has
not been fully understood.Objective: To investigate the impact of past maximum BMI on the subsequentdevelopment of diabetic complications.Methods: One hundred inpatients with type 2 diabetes were divided
into 3 groups according to each patient's past maximum BMI; Group A: 25<BMI<30, Group B: 30<BMI<35 andGroup C: 35<BMI. There were no significant differences in mean age, duration of diabetes and HbA1C among
all groups. And we compared the prevalence of diabetic complications as well as other obesity-related
complications among groups retrospectively.Results: Mean past maximum BMI of each group (Group A, B andC) were 28.4, 32.1 and 37.3 respectively. In group C, the difference between past maximum BMI and meancurrent BMI (30.2) was greater than in other groups. A rate of Insulin use was significantly higher inGroup C than in Group A (Odd ratio: 6.3). With increase in past maximum BMI, the prevalence of diabetic
retinopathy, nephropathy and neuropathy became higher (Odd ratio; retinopathy: 3.4, 7.6, nephropathy:
3.9, 12.3 and neuropathy: 6.9, 14.8). The prevalence of diabetic macro angiopathy (includes coronary
artery disease, cerebral infarction and peripheral artery disease) also tended to be higher in GroupC than in other groups (Odd ratio: 2.1, 2.7). Arterial stiffness (evaluated by cardio-ankle vascularindex) was significantly higher in Group C than in Group A (7.7vs9.8). The prevalence of the otherobesity-related complications (sleep apnea syndrome, osteoarthritis, liver dysfunction) showed similar
results.Conclusion: Degree of obesity may associate with future development of obesity-related
complications, especially with diabetic complications.

Background: The impact of a degree of obesity on the development of diabetic and other obesity-related
complications is not fully understood.Objective: To investigate the impact of a maximum BMI in the pasthistory on the development of diabetic and other obesity-related complications.Methods: One hundred
inpatients with type 2 diabetes were divided into 3 groups according to each patients maximum BMI in
the past history (max BMI); Group A: 25<BMI<30, Group B: 30<BMI<35 and Group C: 35<BMI. And we compared
the prevalence of diabetic complications as well as other obesity-related complications amonggroups.Results: Mean max BMI (Group A, B and C) were 28.4, 32.1 and 37.3 respectively. In all groups,
mean present BMI (25.8, 27.4 and 30.2) were significantly lower than those of max BMI. There were no
significant differences in mean age, duration of diabetes and HbA1C among all groups. A rate of Insulin
use was significantly higher in Group C than Group A (Odd ratio: 6.3). The prevalence of diabetic
retinopathy, nephropathy and neuropathy became higher accompanied with increased max BMI (Odd ratio;
retinopathy: 3.4, 7.6, nephropathy: 3.9, 12.3 and neuropathy: 6.9, 14.8). The prevalence of diabetic
macro angiopathy (includes coronary artery disease, cerebral infarction and peripheral artery disease)tended to be higher in Group C than the other groups (Odd ratio: 2.1, 2.7). Arterial stiffness (evaluatedby cardio-ankle vascular index) was significantly higher in Group C than Group A (7.7 vs 9.8). The
prevalence of the other obesity-related complications (sleep apnea syndrome, osteoarthritis, liver
dysfunction) showed similar results.Conclusion: A degree of obesity in the past history might beassociatedwithcomplications.

thedevelopmentofobesity-related

complications,especiallywithdiabeticPsychosocial Assessments of Japanese Severe Obese Patients before Intragastric Balloon Placement
Therapy.

1

Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The Universityof Tokyo, Tokyo, Japan 2Depertment of Gastrointestinal Surgery, Graduate School of Medicine, The
University of Tokyo, Tokyo, Japan 3Department of Diabetes and Metabolic Diseases, Graduate School of
Medicine, The University of Tokyo, Tokyo, Japan
Shuji

Inada1,Yoshiyuki

Takimoto1,Kazuhiro

Yoshiuchi1,FumihikoHatao2,Yusuke

Hada3,Sumie

Okahata3,Toshimasa Yamauchi3,Takashi Kadowaki3,Akira Akabayashi1

Bariatric surgery was not so popular in Japan as in other countries. Instead, intragastric balloon
placement therapy has been performed in our hospital since 2007. The results of bariatric surgery andintragastric balloon placement therapy could be influenced by patient's psychosocial factors, and viceversa. Therefore it is important to assess psychosocial factors before procedures. The purpose of thepresent preliminary study is to explore characteristics of psychosocial factors of Japanese obese
candidates for intragastric balloon placement therapy. Eligible patients for this study were adult obese
ones classified to class II or higher (body mass index [BMI] was over 35kg/m2) who applied to receive
intragastric balloon placement therapy. Thirteen male (44.8±8.7 years) and 14 female patients (51.4±9.6 years) were candidates for the therapy and received an initial psychosocial assessment between
2007 and 2010. Mean BMI was 42.6kg/m2 in the male patients and 43.2kg/m2 in the females. Five patients
had psychiatric comorbidity. The psychosocial assessment included an interview about weight history,
lifestyle, and psychiatric history, and questionnaires about mood states, coping skills, self-esteem,
and social support. We evaluated correlations between initial BMI and the psychosocial factors. There
was a significant negative correlation between initial BMI and problem-focused coping (r = -0.485, p= 0.012). In the subscales of the problem-focused coping, planful problem solving (r = -0.393, p = 0.047)
and confrontive coping (r = -0.473, p = 0.015) had negative correlations with BMI. In conclusion, heavier
patients might have poorer ability to solve their own problems including their weight and diet. Because
this study was cross-sectional, it is necessary to assess prospectively the influence of preoperative
psychosocial factors on outcomes of intragastric balloon placement therapy and vice versa.

First experience of laparoscopic sleeve gastrectomy for morbid obesity in our OR

1

Chiba University Hospital, Nursing 2Research Center for Frontier Medical Engineering, Chiba University

3

Department of Frontier Surgery, Graduate School of Medicine, Chiba University

Megumi Kanoh1,Norihiro Kameda1,Yuki Miyake1,Mami Yoshida1,Sizue Komoda1,Hiroshi Kawahira2,Toshiyuki
Natsume3,Hideki Hayashi2,Hisahiro Matsubara3

Introduction: Laparoscopic approach to bariatric surgeries has been penetrating into our country andfirst case of laparoscopic restrictive surgery for morbid obesity has been performed until 2010 in our
hospital. Perioperative nursing experience of the case will be reported.Patient and Methods: A
39-year-old, 132 kg man (height 170cm, BMI 45.7) was planned to undergo laparoscopic sleeve gastrectomy
for weight reduction under general anesthesia. His medical background included hypertension, sleep apnea
and gall stone. Setting in operating theatre was designed on the basis of that for laparoscopic gastrectomy
for gastric cancer in our OR. The patient was positioned supine with thighs abducted and 30 degrees reverse
Trendelenburg. Lithotomy positioning device (LevitatorTM), which was routinely used for the operating
position of laparoscopic gastrectomy, were revealed to be too small for the patient, thus, leg sectionof electric operating table was switched between right and left part to obtain wide area for abductedthighs. Intermittent pneumatic compression devices were also equipped during surgery.Results: Operative
procedures were completed within 3 hours with little blood loss. However, the patient noted numbness
and mild foot drop of right leg right after surgery. Examination by a neurologist on the second
postoperative day revealed right peroneal palsy. Slow, but complete recovery occurred over three month.

Discussions: Photographical review of the OR setting could not reveal any mechanical compression of thesite. However, repeated checkup of the whole body of patient during operation was suggested to be importantto this type of surgery.

The effects of regular advice-messages via to internet with cell phone on diet using formula dietsupplements.

1

Graduate School of Medicine, Study of Medical System Management, Nagoya University 2Clinical Pharmacy,

Department of Pharmacy, Kinjo Gakuin University 3Information Culture, Kinjo Gakuin University
Hiroshi

Gohma1,Mika

Asano2,Yuko

Aoyama1,Rina

Fujii2,Konatsu

Hayashi2,Chihiro

inoue2,Tomomi

Kawanishi2,Katsuo Amioka2,Makoto Nakao2,Sin-ichi Sugiura1

Since WHO has proposed the criteria of metabolic syndrome in 1998, obesity is focused as a risk factorof life-style related diseases.

In the result, many formula diet supplements which aimed weight loss

have been market in the world.

Although the formula diet supplements have nutritional availability,

some users fail to loss their weight due to their lack of knowledge, or gain weight due to the reboundphenomenon.

Therefore it is thought that the formula diet supplements are not effective to weight loss,

despite their price.

However we propose that the users might be able to be loss their weight by giving

advice-messages regularly.

In this study, we evaluated whether the regular advice-messages via tointernet with cell phone were effective to the subjects who intake formula diet supplements. A total
20 subjects with BMI more than 23 were recruited. They were divided into two groups by an advice groupor no advice group.

Each group received formula diet supplements for 12weeks, and was provided

consecutive 12 weeks as follow up.

The advice group was provided an advice-messages everyday during

trial, while the no advice group was provided nothing during same period. We evaluated weight and BMI
as parameter in this study.Each group lost their weight compared to their initial value.
difference was indicated between both groups in their weight and BMI.
that each group intake the formula diet supplements.

No significant

This study was finished the period

Follow up for 12 weeks is performed at present.

We hypothesize that the deference is indicated between both group in their weight and BMI during follow
up period.

We will report the effect of advice-messages during follow up period in the congress.

Hours of nightly nasal continuous positive airway pressure use is associated with weight change inpatients with obstructive sleep apnea-hypopnea syndrome1

Department of Laboratory Medicine, Iwate Medical University School of Medicine, Devision of Behavioral

Sleep Medicine 2Department of Laboratory Sleep Medicine, Iwate Medical University School of Medicine
3

Department of Respirology, Hachinohe Red Cross Hospital

TsuguoNishijima1,Keisuke

Hosokawa1,Sayaka

Ishidoya3,Susumu

Takahashi1,Hiroshi

Kagami3,Keijiro

Suzuki1,Akira Suwabe1,Shigeru Sakurai2

Nasal continuous positive airway pressure (nCPAP) is known to alleviate sleep-related disturbances andmay reduce the risk of hypertension and cardiovascular disease. Using an electronic database of numberof hours of nightly CPAP use, we estimated the habitual sleep time of patients during nCPAP and examined
its relationship to association with changes in body weight. In obese patients with obstructive sleep
apnea-hypopnea syndrome (OSAHS), percent weight gain over 9 years displayed a U-shaped relationship withthe minimal weight gain in patients with 5 to 6 hours of habitual sleep. In contrast, weight gain was
the largest in patients with sleep time of less than 4 hours per night or more than 8 hours per night.
These results suggest that changes in body weight in patients with OSAHS are associated more with habitual
sleep time.

Title:Successful application of a new stapler with reinforcement installed to sleeve gastrectomy inbariatric surgery

Hiroko TORII MD*, Yuhki OZAMOTO MD*#, Takeshi TOGAWA MD, PhD*#, Isao KAWAMURA MD, PhD+, Akeo HAGIWARA
MD, PhD#*Kusatu General Hospital, #Doshisha University, +Kamagaya General HospitalIn patients undergoing sleeve gastrectomy, the gastric wall is often thick and readily breakable due
to adipose tissue accumulating in the submucosa and the musclularis. When sleeve gastrectomy is performedon such patients, conventional staplers often break or fail to suture the thick and fragile gastric wall,
sometimes resulting in serious post-operative complications such as bleeding and/or anastomotic leakage.
As a countermeasure for this problem, we have used a newly available type of stapler, which sandwiches
a strip of reinforcement between the staples and the tissue. By stapling the gastric wall from thereinforcement layered atop, the stapler prevents breaking of the tissue and ineffective stapling. The
layer of the reinforcement and the gastric wall seems to have a proper physical strength for stapling.
Since the introduction of the device, we have experienced no post-operative complications stemming fromsuture errors. This new stapler can be useful in sleeve gastrectomy.

Enhanced glucagon-like peptide (GLP-1) secretion leads to rapid improvement of glucose tolerance andinsulin secretion after laparoscopic sleeve gastrectomy (LSG)

Satoshi Ugi1, Hiroshi Yamamoto2, Chisato Kusunoki1, Azusa Kamo1, Tetsuya Hashimoto1, Yoshihiko Nishio1,
Kazunori Kasama3, Toru Tani2, Atsunori Kashiwagi1, and Hiroshi Maegawa1
Departments of 1Medicine and 2Surgery, Shiga University of Medical Science, and 3Yotsuya Medicalcube
Hospital【Objective】 Bariatric surgery, especially Roux-en-Y gastric bypass (RYGP), has been shown to resolve
T2DM. Although the mechanism by which RYGP improves T2DM have yet to be fully determined, the most possible
mechanism of this is assumed to be increment of GLP-1 secretion. LSG has been designed as the first of
a two-stage procedure for the high-risk, super-obese patient. Recently LSG has been studied as asingle-stage procedure because of excellent weight loss and low incidence of complications. However,
little is known about the impact of LSG on glucose homeostasis. We performed LSG in two diabetic patientsand both showed rapid and profound improvement of glucose tolerance after LSG.
【Methods】 We performed glucose tolerance test (GTT) before and twenty days after surgery and analyzed
area under the curve of plasma glucose, insulin and GLP-1 ; AUCglucose (mg/dl‧hr), AUCinsulin (U/ml‧hr),
AUCGLP-1 (pmol/l‧hr), and fasting ghrelin levels.
【Results】The first case had received metoformin 750mg/day for three years. HbA1c was 6.3%. Twenty days
after surgery, BMI decreased from 38.0 to 36.4 (-4.1kg). Although AUCglucose slightly decreased (510 to457), both AUCinsulin and AUCGLP-1 dramatically increased (122 to 216 and 6.4 to 68.5, respectively). Threemonths after surgery, HbA1c was 5.5% without medication. Second case also showed great improvement of
glucose tolerance with enhancement of insulin and GLP-1 secretion. Ghrelin levels were significantly
decreased in both cases.

Enhanced GLP-1 secretion is specific to bariatric surgery, because weight

reduction by diet therapy did not enhance GLP-1 secretion.
【Conclusion】 These results suggest that LSG can lead to rapid improvement of glucose tolerance andinsulin secretion along with GLP-1 secretion. Reduction in ghrelin levels may also contribute toimprovement of glucose tolerance. Thus, LSG will be ideal procedure for obesity with T2DM.

Duodenal switch for failed gastric banding

Dr Daniel KRAWCZYKOWSKI, Dr Youssef El SOUKI
Centre Hospitalier Regional de Metz FRANCE

Background
Biliopancreatic duodenal switch (BPD/DS) has 2 components: a restrictive one the sleeve
gastrectomy (SG) and a malabsorptive one the duodenal switch (DS). Each of the twocomponents can be performed separately.
MethodBetween May 2003 and July 2008, 38 patients with an uncomplicated and well tolerated
adjustable gastric banding (AGB) sustained an additional DS for an inadequate initialexcess BMI loss (IEBMIL) (BMI >30) or for persisting curable co-morbid condition. Most of
the bands were kept deflated.
Results
So far, 16 patients remained with the band associated to the DS while 22 patients had alater band removal for convenience, intolerance or IEWL (6 patients had a conversion to SG
and 16 patients are free of any restriction). All glycemic and high cholesterol problems
were resolved.

BMI before BMI before Type ofAGB
DSrestriction

46.9 (35.4– 61.7)40.9 ±
6.9

Differential evolution of
BMI% IEBMILAt 1 YAt 2 YAt 1 YAt 2 YAGB

32.3±530.6±4.5

67.5±22.8

65.9±18.9SG

29.9±7.6

28.6±3.877.2±16.2

81.9±11.9

Without33.7±5.5
restriction

32.9±6.0

61.8±24.8

64.9±29.5

Conclusion:
Additional DS is feasible. With or without any restriction, it contributes to patientsweight loss and to resolve curable co-morbid condition. Although AGB + DS, isolated DS or
debanding and SG and are options for failure AGB further studies are needed.