Anesthetic Management of 186 morbidly obese patients for Bariatric Surgery

1

Minimally Invasive Surgery Center, Yotsuya Medical Cube, Tokyo, Japan 2Department of Weight Loss Sugery,Yotsuya Medical Cube, Tokyo, Japan
ToshieShiraishi1,Kazuko

Sonoda1,Eri

Kikkawa2,Tetsuya

Nakazato2,Hideharu

Shimizu2,YosukeSeki2,Yoshimochi Kurokawa1,Kazunori Kasama2

BackgroundWe have experience of anesthetizing 186 morbidly obese patients for Bariatric Surgery of which
50 patients had Laparoscopic Roux-en-Y Gastric Bypass (LRYGB), 41 patients had Laparoscopic Sleeve
Gastrectomy with Duodenojejunal Bypass (LSG/DJB), 78 patients had Laparoscopic Sleeve Gastrectomy (LSG),
and 17 patients had Laparoscopic Gastric Banding (LAGB) between June 2006 and October 2010. We
retrospectively evaluated the background of patients, pre-operative complications (such as airway
difficulties, intra-operative events, duration of anesthesia and the operation) and some otherpoints.ResultMean age and body mass index of the patients were 38 years±10 years and 44 kg/m2±9 kg/m2.
As for pre-operative complications, there were 83 patients (44%) with hypertension, 83 patients (44%)
with Diabetes Mellitus, 88 patients (47%) with Sleep Apnea Syndrome (Apnea Hypopnea Index>20), 26 patients(14%) with asthma, 34 patients (18%) with a mental disorder such as depression. Using the Mallampati
Classification (evaluation for difficult laryngoscopy),

29 patients (16%) were class III or IV which

predicted difficult laryngoscopy. We performed conscious endotracheal tube intubation on 7 patients (5%).
Anesthetic agents used were basically O2-Air-Sevoflurane with added propofol, fentanyl, andremifentanyl. During the operations, a severe decrease in SpO2 or blood pressure and deadly arrhythmias
did not occur in any patient. Delayed wakening was also not found and all extubations were performedin the operating room. There was one patient that just after the extubation, experienced a very low level
decrease in SpO2 but recovered immediately. There were no re-intubation patients after thesurgery.ConclusionThere were no anesthetic problems or complications in any patients. There are many
important risks or caring points concerning anesthesia for morbidly obese patients, but the biggest issue
seems to be the respiratory management. In addition, there are some unclear issues which we should discuss
more such as fluid therapy and drug dosing.

The Role of Proton Pump Inhibitor in Quality of Nursing Care in Sleeve Gastrectomy1

E-Da Bariatric & Metabolic International Surgery Center,Taiwan

Li-ChunLin1,Chi-Hsien Lo1,Chih-Kun

Huang1

AbstractBackground: Recent a few years, laparoscopic sleeve gastrectomy (LSG) is gaining ground as a
new option for the treatment of morbid obesity in Asia-Pacific area. But postoperative reflux symptoms
bothered the patient and caring nurse. The aim of this study is to evaluate whether proton pump inhibitors(PPI) prior to the surgery can improve the quality of nursing care.Methods: From February 2009 to Octoberof 2010, 34 morbid obese patients underwent laparoscopic sleeve gastrectomy. Preoperatively intravenous
PPI was prescribed to 16 patients (group A) and no PPI was given to 18 patients (group B). Both groups
were compared in the length of hospital stay, operation time, Visual analogue scale (VAS) pain score
and medications frequency (analgesic and anti-emetic). Results: All of 34 patients (15 men and 19 women)
underwent laparoscopic sleeve gastrectomy with Fr 38 bougie. No difference of sex, age, comorbidity and
BMI was noted in these two groups. Operation time was 53.5 minutes for group A and 59.89 minutes forgroup B without statistic difference. No differences were found in frequency of morphine injection and
VAS pain score in early postoperative and discharge time. Two complications happened, one postoperative
bleeding in group A and one staple leakage in group B. The frequency of additional antiemic use(Prochlorperazine) was higher in group B (38.9% vs.6.3%) (p = 0.025). The length of hospital stay was
shorter in group A (3.19 vs. 4.00) (p= 0.025). Conclusion: Laparoscopic sleeve gastrectomy is a safe
procedure with low morbidity. After surgery, the reflux and vomiting can lead to discomfort, increased
use of anti-emetic and prolonged the hospital stay. Preoperative PPI use demonstrated an effective method
to contour this problematic and improved the quality of nursing care for sleeve gastrectomy
perioperatively.

Economic evaluation of bariatric surgery

1

Health management research center, Ritsumeikan Univ., Shiga, Japan 2Shiga medical univ. 3Yotsuya medical

cube
Hiroaki Kakihara1,Hiroshi Yamamoto2,Toru Tani2,Kazunori Kasama3,Tetsuya Nakazato3

Purpose: Economic evaluation of bariatric surgery Methods: 31 bariatric surgery patients of Yotsuya
Medical Cube, who had follow-up appointments after May 2008, were surveyed. The surveys included questions
pertaining to their expenditures before and after their surgeries. Results: The average medical
expenditure for preoperative patients is 12,597 yen per month. There were seven patients who reported
to have no medical expenditures before their operation. Without them, the average becomes 16,270 yen
per month. Post operation, the number of patients who reported to have no medical expenditures increased
to 11. The average medical expenditure for postoperative patients was found to be 3,286 yen per month.
This means that an average of 9,311 yen decrease per patient, totaling 111,732 yen per year. Furthermore,
the social medical cost was decreased by 372,440 yen. In addition, medical related financial expenditures
for food, transportation, supplements, entertainment, and utilities decreased. On the other hand,
expenditures for items such as clothing, and beauty/hairdressing costs increased. Overall, there wasa decrease of 40,546 yen per patient. Analysis: It is thought that the annual medical cost reduction
effect lasts and even increases with the age of the patient. If a patient was 30 years old at the timeof operation, and it was assumed that they lived to be 80, a medical expenditure decrease of 18,622,000
yen is expected according to the data collected from the survey. This means that the present value after
3% discount from the interest would be 9,870,277 yen. From the patient's point of view, the medical cost(not including what is covered by insurance) is 2,300,000 yen, which could be collected in less than
five years (57 months) . It can be said that it is a very advantageous investment of 10 times of long-term
national bond interest rate of 2.1% for 20 years.

Measuring our success: how well do we follow our patients?

1

Australian Institue of Weight Control, Perth, Western Australia

Susan F. Taylor1,Jeff M. Hamdorf1,Jeremy Tan1

The importance of developing protocols for patient care in many fields, including Bariatric Surgery,has been emphasised by many authors.

Prospective data collection is essential in a successful clinicalservice to enable robust self-audit and promote the opportunity to compare clinical services andcritically evaluate outcomes against external metrics. As part of the Perth Circle of Care Bariatricprogram, our surgeons and physicians are committed to thorough and regular follow up. In preparation
for protocol improvement, we conducted an audit of our compliance with existing follow up protocols anddata entry over three years spanning the introduction of electronic health records. In 2008, before theelectronic system was in place, 114 (62%) of 183 postoperative patients were seen within 4 weeks of thesix months post operative review point, yet 142 (78%) attended within 4 weeks of the scheduled 12 monthreview. The new system was implemented at the beginning of 2009, and appointments were more consistently
adherent to the followup protocol. In
the 6 month

2010, we have demonstrated continued satisfactory adherence tofollowup protocol. 10% of visits recorded changes in co-morbidities, which reflects ourpractice of thorough enquiry at initial assessment. This review of our collected data provides opportunity
to improve our assessment of the patients at these sentinel reviews.

IS ROUTINE PREOPERATIVE POLYSOMNOGRAPHY NECESSARY IN PATIENTS HAVING BARIATRIC SURGERY?

1DIVISION OF BARIATRIC/MINIMALLY INVASIVE SURGERY,STATEN ISLAND UNIVERSITY HOSPITAL, STATEN ISLANDNEW YORK.
KAREN E. GIBBS1,ABDUL S. BANGURA1,STELIN JOHNSON1

Background: Obstructive sleep apnea (OSA) is recognized in obese patients.It maybe associated withsignificant perioperative morbidity and mortality.Polysomnography remains the gold standard for the
diagnosis and assessment of the severity of OSA. Some Bariatric centers adopt a selective screening
approach based on clinical suspicion; others, screen every patient. The aim of our study is to determine
the prevalence of OSA , and whether BMI correlates with OSA prevalence. These results will form the basis
for making a case for or against routine preoperative polysomnography in patients having bariatricsurgery. Methods: A five year(2005- 2010) retrospective chart review was performed.Patients demographic
and sleep study data was collected and analyzed. The severity of OSA was divided into mild, moderateor severe according to the American Sleep Disorders Association guidelines. Mild OSA is defined as anapnea/hypopnea index of 5-15, moderate as 15-30 and severe as &gt30 . Results were analyzed using
statistical software.Results: 555 patient charts were reviewed. Of these, 359(65%) had polysomnography.
309(86%) of the 359 patients had OSA , 50(14%) had no OSA. The overall prevalence of sleep apnea was
86%, mild OSA 18%(63/359), moderate OSA 17%(62/359), severe OSA 51%(184/359). The prevalence of OSA by
BMI category was as follows: BMI(35-39.9 kg/m2): 92%(34/37). BMI(40-49.9 kg/m2): 82%(178/218).
BMI(50-59.9 kg/m2): 92%(78/85). BMI(&gt60 kg/m2): 100%(19/19).Conclusion: OSA is highly prevalent(86%)
in our patient population, with most of them(51%) having severe OSA.OSA is highly prevalent in all BMI
categories. However,a BMI &gt60 kg/m2 correlates with a 100% prevalence of OSA.Based on theseresults,routine polysomnography is necessary as part of the pre operative work up for all bariatricpatients .

IS ROUTINE PREOPERATIVE VENOUS DUPLEX SCREENING NECESSARY FOR PATIENTS HAVING BARIATRIC SURGERY?

1DIVISION OF BARIATRIC/MINIMALLY INVASIVE SURGERY, STATEN ISLAND UNIVERSITY HOSPITAL, STATEN ISLAND ,NEW YORK.
KAREN E. GIBBS1,ABDUL S. BANGURA1,STELIN JOHNSON1

Background:Morbidly obese patients are perceived to be at high risk for perioperative deep veinthrombosis(DVT). Routine preoperative bilateral lower extremity venous duplex screening for DVT is apart of their preoperative work up in many Bariatric centers. The purpose of our study is to determine
the prevalence of

preoperative DVT in our patient population,and form a basis to make a case for oragainst routine preoperative venous duplex screening in bariatric patients.Methods: A five year (20052010) retrospective chart review was performed, of our prospectively maintained bariatric database.
Demographic data and the incidence of preoperative DVT was analyzed using statistical software.Results:
555 patients underwent bariatric surgery during this five year period. 402 (72%) were females, and153(28 %) were males. The age range was 18- 67 (median age 43). 454 (82 %) of patients were Caucasians,
46(8%) were Hispanics, 45(8%) were black and 10(2%)other race. The mean BMI was 47.1(SD 6.8).177 (32%)
patients underwent the Roux-en-y gastric bypass procedure, while 378(68%) had the lap band procedure.
Only one patient with a history of chronic DVT was found to have a positive preoperative venous duplex.
The incidence of preoperative DVT was 0.2%Conclusion: The incidence of preoperative DVT is very low inthese patients. Routine preoperative venous duplex screening is therefore unnecessary. We would suggest
preoperative duplex screening in those patients with a previous history of DVT or evidence of significant
venous insufficiency

Routine Preoperative Barium Swallow to detect Hiatus Hernia in Bariatric Surgery Patients: Is it
Worthwhile?

1

North Queensland Obesity Surgery Centre, Mater Hospital, Townsville, Australia

John Avramovic1,Laura Craig1,Sam Baker1,Christopher Aubrey1

Routine Preoperative Barium Swallow to detect Hiatus Hernia in Bariatric Surgery Patients:
Is it Worthwhile?PurposeTo determine if routine preoperative barium swallow before laparoscopic
bariatric surgery can predict those patients who require crural repair for hiatus hernia.Method100
consecutive patients undergoing bariatric surgery underwent preoperative barium swallow to detect hiatus
hernia. The radiological results were compared to the operative findings.Results98 patients underwent
a complete radiological study. 17 patients were reported to have a hiatus hernia radiologically. 37
patients were found to have a hiatus hernia at operation, and had a sutured anterior crural repair as
per

our

unit

protocol.

Operative

Finding

Hiatus hernia

No Hiatus HerniaRadiological

Hiatus Hernia-

7

10 Finding

No Hiatus Hernia

30

51 The true positive rate was 7%. The calculated sensitivity

for barium swallow in detecting a hiatus hernia prior to surgery was 21%.
had

a

41%

probabilityofdetectingahiatushernia-A positive barium swallow

subsequently

confirmedatsurgery.ConclusionPreoperative barium swallow in morbidly obese patients undergoing laparoscopic
bariatric surgery was poor at predicting the presence of hiatus hernia. Routine barium swallow prior
to bariatric surgery for the detection of hiatus hernia was unreliable and not warranted.

IS ROUTINE PREOPERATIVE UPPER ENDOSCOPY NECESSARY FOR PATIENTS HAVING BARIATRIC SURGERY?

1DIVISION OF BARITRIC/ MINIMALLY INVASIVE SURGERY, STATEN ISLAND UNIVERSITY HOSPITAL, STATEN ISLAND,NEW YORK.
KAREN E. GIBBS1,ABDUL S. BANGURA1,STELIN JOHNSON1

Background: Upper endoscopy is a routine preoperative investigation in patients undergoing bariatric
operations in most bariatric centers.However,the level of evidence supporting this recommendation israther not strong.The rationale for performing upper endoscopy is to detect and treat lesions that might
potentially affect the type of surgery performed. The aim of our study is to analyze the prevalalenceof the various findings on preoperative upper endoscopy in our patient population, and to evaluate howthese findings impacted the choice of surgery.Methods: A five year(2005-2010)retrospective chart review
was performed,of our prospectively maintained bariatric database. Patient demographics,and endoscopy
findings were collated. The prevalence of endoscopic findings was analyzed using statistical soft
ware.Results: 555 patient charts were reviewed, 389(70%) of these had preoperative upper endoscopy.
381(98%) of the 389 patients that had endoscopy show positive findings, 8(2%)patients had normal findings.
More than 90% of patients had a combination of at least two findings. The prevalence of individual findings
are as follows: GASTRITIS: 92%(359/389), HIATAL HERNIA: 35 %(137/389). ESOPHAGITIS: 24%(94/389),
HELICOBACTER PYLORI: 13%(50/389), DUODENITIS: 5%(20/389), POLYPS: 2%(8/389),ULCERS:0.2% (1/389),
TUMORS(LIPOMA):0.2%(1/389), BARRETTS 0.2%(1/389). Conclusion: Upper endoscopy has a high incidence of
positive findings (98%) in bariatric patients, the most common being gastritis and hiatal hernia. The
findings did not change the operative management for these patients. Given that patients are evaluatedfor hiatal hernias at the time of surgery, preoperative endoscopy is not necessary to make this diagnosis.
Thus, routine preoperative upper endoscopy is unnecessary in the work-up of bariatric patients.

Outcomes and options in the management of leak and gastric fistula after sleeve gastrectomy.

1

Mercy Bariatrics, Perth Australia

Leon Cohen1

Leak and gastric fistula after sleeve gastrectomy remains one of the most feared and difficultcomplications to deal with after sleeve gastrectomy. The incidence in the published literature ranges
from 2-5% and is increased in revisional surgery.Over the last 6 years we have performed over 850 sleeve
gastrectomies and have had leaks in 24 patients, ( 3% ) in addition there have been 19 infected perigastrichaematomas in which no leak was demonstrated.Management of these patients can be divided into early,
middle and late. All patients required early laparoscopic lavage and drainage. Immediate control of leakby oversew or restapling was possible in only two patients .Twenty two patients went on to develop chronic
gastric fistulas with spontaneous resolution in 14. Eight patient have required delayed open gastrectomyor Roux en y internal fistula drainage as a salvage procedure for Chronic leaks. There has been one latedeath in this group during surgery at 6 months post leak. Weight loss in the leak group is comparable
to uncomplicated patients.Use of additional manouveres including stenting, gluing , feeding jejunostomy,
percutaneous drainage, Botox and plugging will be discussed.
Conclusion: Leak after sleeve gastrectomy is a devastating complication that can be difficult to manage.
Using a sequential and logical approach the situation can be successfully managed with resolution of
the leak and good outcomes.

Superior mesenteric venous thrombosis after revisional open sleeve gastrectomy

1

Toho University Sakura Medical Center, Chiba, Japan

Takashi

Oshiro1,Yutaka

Yoshida1,Daisuke

Horibe1,Mitsuru

Oshiro1,Makoto

Nagashima1,Atsuto

Saiki1,Shinichi Okazumi1,Ryouji Kato1,Kohji Shirai1,Isao Kawamura1

A 44 year-old man with morbid obesity (BMI49), hypertension, obstructive sleep apnoea-hypopnea and stasis
phlebitis visited our hospital for revisional bariatric surgery for inadequate weight loss. He had hadvertical banded gastroplasty (VBG) 20 years ago at other hospital. However he regained weight 7 years
after the surgery probably due to staple line disruption and has been lost to follow-up. Preoperative
gastroscopy confirmed staple line breakdown. Open sleeve gastrectomy as revisional surgery was
successfully carried out. The patients underwent thromboprophylaxis using subcutaneous heparin calcium
injection (5000 IU preoperatively, followed by 10000 IU daily postoperatively for 3 days). He developed
fever and vague abdominal pain 14 days after the operation. His C-reactive protein and D-dimer were
elevated to 20.4 mg/dl and 18.8 μ g/ml, respectively. Computed tomography (CT) revealed superior
mesenteric venous thrombosis and mesenteric panniculitis. Intravenous heparin and oral warfarin wereimmediately started. The patient's symptom and laboratory data were improved thereafter. Follow-up CT
showed no further development of thrombosis. He continues on oral warfarin (5mg per day). At three months
after the operation, he achieved 30 kg weight loss and did well. Mesenteric venous thrombosis is a rare
condition that should remain in the differential diagnosis for patients presenting with abdominal pain
after the bariatric surgery. The prompt diagnosis and anticoagulant therapy can produce favorable
outcomes.

Staple line complications during bariatric surgery

1

Department of General Surgery, Singapore General Hospital, Singapore

Shanker Pasupathy1,Wai Keong Wong1

Background:Bariatric surgery is accepted as the most effective treatment for morbidly obese individuals.
In current practice, the majority of procedures are performed by laparoscopy. Hence surgeons are highly
dependent on modern laparoscopic instrumentation, in particular endoscopic staplers.Aims:To investigate
the incidence and impact of staple line failures during bariatric surgery.Methods:Retrospective review
of all bariatric surgical procedures performed at the Singapore General Hospital. The use of staplers,and occurrence of intra-operative and post-operative complications related to stapling wasnoted.Results:From January 2003 to November 2010, 70 bariatric procedures were performed: 23 laparoscopic
adjustable gastric bands (AGB) and 47 laparoscopic stapled procedures comprising 37 sleeve gastrectomies(LSG), 9 gastric bypass (LGB) and 1 bilio-pancreatic diversion (BPD). Re-inforcement with buttressmaterials or suture inversion of staple lines was not performed routinely. There were 3 intra-operative
staple line failures (6%) resulting in haemorrhage (1 case) and gaping of the staple line (2 cases).
All 3 failures were rescued by suturing and did not affect the surgical outcome. There were 3
post-operative staple line-related complications (6%) requiring re-operation within 24 - 48 hours. 2
patients had haemorrhage from the gastric staple line and 1 patient had an anastomotic leak from ajejuno-jejunostomy (which was preceded by intra-luminal bleeding and bowel obstruction by blood clots).
All staple lines were repaired by suturing during re-operation and the patients did well post-operatively
with no further incidents.Conclusion:Staple line complications are relatively common and may be due to
instrument failures or technical failures by the surgical team. It is essential to thoroughly inspect
all staple lines and have an effective rescue strategy at hand to manage failures before complications
develop.

Drains are not necessary in laparoscopic gastric bypass

1

Surgery Department, Riyadh Military Hospital, Riyadh, Saudi Arabia

Haider Alshurafa1

Objective: To prove that the surgical drains are not necessary in routine laparoscopic gastricbypassMethod: This is a retrospective review for the files of all patients who have underwent
laparoscopic gastric bypass over one year with no surgical drains.Results: There were 104 patients who
have laparoscopic gastric bypass in the period between April 2009 and the end of the July 2010. All thesepatients have primary laparoscopic gastric bypass. They are 78 female and 26 males patients and the age
range between 15 and 62 years with average age of 38.2 years. The BMI range between 34 to 53.8 kg/m2,
the mean is 44kg/m2. All those patients have no surgical drain. There were no mortality, and one patientneeded laparoscopic drainage of infected collection at left sub-phrenic region after 7 days from theoperations. There is one patient needed needle aspiration of left pleural reactive effusion withconservative management of left sub-phrenic small hematoma. No other immediate post operativecomplications.Conclusion: None use of surgical drain post laparoscopic gastric bypass has no major side
effects and surgical drain should only used in selected cases and when there is indications.

Is the long staple line reinforcement needed or not during laparoscopic sleeve gastrectomy?

1

Department of Surgery, Soonchunhyang University School of Medicine

Yong Jin Kim1,Kyung Yul Hur1

Purpose: To evaluate the effect of staple line reinforcement during laparoscopic sleeve gastrectomy(LSG).
Method: Between April 2009 and September 2010, we did LSG for morbidly obese 81 patients. Staple line
reinforcement was not done for early 30 patients(group 1) and was done late 51 patients(group 2). We
compared the outcomes according to bleeding, leak, stricture or obstruction. Result: There were nodifferences in age, sex, preoperative weight and body mass index. Mean operation time was 129
minutes(group 1) & 103minutes(group 2).(p=0.027) Staple line related complication was observed in 3
cases(1, leak/2, obstruction due to kinking) only in group 1.(p=0.048) There was no complication in group
2. Re-operation was done in a leak case and there were no in-hospital mortality. Conclusion: Although
there are some limitation for retrospective analysis and learning curve, we conclude that long staple
line reinforcement was effective to prevent staple line related complications.

The safety and advantages of applying clips in sleeve gasterectomy

1

Department of Surgery,King Saud University,King Saud University,Riyadh,Saudi ARABIA

Abdullah Aldohayan1,Fahad Bamehriz2,Mohhamad Alnaami3,Alanezy

Naif4

Since the introduction of sleeve gastrectomy gained widespread popularity. However the complication of
bleeding and leakage may limit its advantage. Leakage and bleeding are usually managed by suturing orother method. We study the efficacy and safety by using the clips on the staple line on 74 patientswith BMI in more 40 over 2 years. The clips were applied on staple gastric line. There was leak or heamatoma
need to be spiraled.More over applying the clips is shorter in time and easier than using suture.The
usage of clips is safe, easy and decrease the bleeding may prevent leakage further extension of work
may prove its metros

Laparoscopic Duodeno-jejunal Bypass with Sleeve: How we do it and management of a possible complication

1

Department of Bariatric and Metabolic Surgery,Gem Hospital and Research Centre,Coimbatore,India

Praveen Raj1,Palanivelu Chinnusamy1

Background:A few reports of Laparoscopic Duodenojejunal bypass with Sleeve has demonstrated it as a goodalternative to Roux and Y gastric bypass in weight control and resolution of comorbidities .Such a
procedure

specially important in Asian countries where the incidence of Gastric cancer is high. DJB

with sleeve gastrectomy is proposed as an ideal alternative to RYBG with the stated advantages -1. Presenceof difficult to access gastric remnant in RYGB is at risk of cancer development in high endemic regions.
Endoscopic surveillance is easy in sleeve gastrectomy.2. Preservation of pyloric mechanism prevents
dumping syndrome.3. Reduced alimentary limb tension.With very few reports, the technique of thisprocedure is yet to be standardized.Video:In this High Definition video we demonstrate our techniqueof Laparoscopic Duodeno jejunal bypass with Sleeve, Sleeve being performed 5 cm from the pylorus on a
36F bougie, wherein the duodenojejunal anastamosis is done in a retrocolic fashion in end-end hand sewn
method. The biliopancreatic limb length is 75 cms and that of the Roux limb is 100cm, similar to a standard
Roux en Y gastric bypass.In the second part of the video, we show a case of internal herniation in the
retrocolic window 1 month post-op in a patient operated with Duodenojejunal bypass and how we managed
the same.

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.